Healthcare Provider Details

I. General information

NPI: 1619706736
Provider Name (Legal Business Name): KIMBERLY WALLGREN MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14241 GRAND OAKS DR
BAXTER MN
56425-8749
US

IV. Provider business mailing address

14241 GRAND OAKS DR
BAXTER MN
56425-8749
US

V. Phone/Fax

Practice location:
  • Phone: 218-316-3109
  • Fax:
Mailing address:
  • Phone: 218-316-3109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number266696
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: