Healthcare Provider Details

I. General information

NPI: 1457339012
Provider Name (Legal Business Name): GREGG WAHLSTROM
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14000 FAIRVIEW DR
BURNSVILLE MN
55337-5713
US

IV. Provider business mailing address

6465 WAYZATA BLVD STE 315
MINNEAPOLIS MN
55426-1728
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-8608
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2420
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number194
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: