Provider Demographics
NPI:1912578188
Name:WALLENFELSZ, EVAN M (LICSW)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:M
Last Name:WALLENFELSZ
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:EVAN
Other - Middle Name:M
Other - Last Name:KOLBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2495 MAPLEWOOD DR N STE 312
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1985
Mailing Address - Country:US
Mailing Address - Phone:651-760-3109
Mailing Address - Fax:651-760-3109
Practice Address - Street 1:2495 MAPLEWOOD DR N STE 312
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1985
Practice Address - Country:US
Practice Address - Phone:651-760-3109
Practice Address - Fax:651-760-3109
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25117104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker