Healthcare Provider Details

I. General information

NPI: 1568766244
Provider Name (Legal Business Name): MARIKEN WOGSTAD-HANSEN, PHD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 01/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 SNELLING AVE N SUITE 230
SAINT PAUL MN
55104-6753
US

IV. Provider business mailing address

91 SNELLING AVE N SUITE 230
SAINT PAUL MN
55104-6753
US

V. Phone/Fax

Practice location:
  • Phone: 651-603-0540
  • Fax: 651-603-0541
Mailing address:
  • Phone: 651-603-0540
  • Fax: 651-603-0541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: DR. MARIKEN ELLEN WOGSTAD-HANSEN
Title or Position: PHD, LP, RN, CNS
Credential: PHD, LP, RN, CNS
Phone: 651-603-0540