Healthcare Provider Details

I. General information

NPI: 1164967360
Provider Name (Legal Business Name): KAREN SUE WURTZBERGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2016
Last Update Date: 12/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SILVER LAKE RD NW
NEW BRIGHTON MN
55112-1786
US

IV. Provider business mailing address

14688 RIDGEWAY RD
CROSSLAKE MN
56442-2773
US

V. Phone/Fax

Practice location:
  • Phone: 651-288-0245
  • Fax:
Mailing address:
  • Phone: 218-838-7518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: