Provider Demographics
NPI:1780128306
Name:HULTGREN, MELANIE NATASHA GABRIELLE (PHD, LMFT)
Entity type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:NATASHA GABRIELLE
Last Name:HULTGREN
Suffix:
Gender:F
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:NATASHA GABRIELLE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12800 WHITEWATER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-9347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12800 WHITEWATER DR STE 100
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9347
Practice Address - Country:US
Practice Address - Phone:763-306-9057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-16
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2456106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1780128306OtherNPI I