Provider Demographics
NPI:1184870610
Name:STOLTENBERG, MAX RICHARD (MC, LPCC)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:RICHARD
Last Name:STOLTENBERG
Suffix:
Gender:M
Credentials:MC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:5700 BOTTINEAU BLVD STE 210
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-3184
Practice Address - Country:US
Practice Address - Phone:763-330-2774
Practice Address - Fax:763-330-2775
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-15
Last Update Date:2024-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3699101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional