Provider Demographics
NPI:1528711629
Name:BURKSTALLER, JOHANNA WENHUA (LICSW)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:WENHUA
Last Name:BURKSTALLER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1827 ENGLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:508-277-2569
Mailing Address - Fax:
Practice Address - Street 1:12301 WHITEWATER DRIVE
Practice Address - Street 2:#30
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343
Practice Address - Country:US
Practice Address - Phone:508-277-2569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN268291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical