Provider Demographics
NPI:1144625708
Name:WAHLSTROM, DONNA
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:WAHLSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1264 HARBOR ST
Mailing Address - Street 2:
Mailing Address - City:OGILVIE
Mailing Address - State:MN
Mailing Address - Zip Code:56358-3621
Mailing Address - Country:US
Mailing Address - Phone:320-272-4897
Mailing Address - Fax:
Practice Address - Street 1:105 6TH AVE S
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-1819
Practice Address - Country:US
Practice Address - Phone:763-308-0006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303084101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)