Provider Demographics
NPI:1780700039
Name:WOGSTAD-HANSEN, MARIKEN ELLEN (PHD, LP, RN, CNS)
Entity type:Individual
Prefix:DR
First Name:MARIKEN
Middle Name:ELLEN
Last Name:WOGSTAD-HANSEN
Suffix:
Gender:F
Credentials:PHD, LP, RN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 SNELLING AVE N
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6753
Mailing Address - Country:US
Mailing Address - Phone:651-603-0540
Mailing Address - Fax:651-603-0541
Practice Address - Street 1:91 SNELLING AVE N
Practice Address - Street 2:SUITE 230
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6753
Practice Address - Country:US
Practice Address - Phone:651-603-0540
Practice Address - Fax:651-603-0541
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3116103TC0700X, 103T00000X, 103TP2701X
MNR0803692163WP0809X, 364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Not Answered163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Not Answered364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN330L9WOOtherBLUE CROSS, RN, CNS
MN385K0WOOtherBLUE CROSS, PHD, LP