Provider Demographics
NPI:1538296520
Name:WOLLENBURG, LINDA G
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:G
Last Name:WOLLENBURG
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LINDA
Other - Middle Name:GAIL
Other - Last Name:BOYENGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:22064 565TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912
Mailing Address - Country:US
Mailing Address - Phone:507-433-7988
Mailing Address - Fax:
Practice Address - Street 1:203 WEST CLARK STREET
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007
Practice Address - Country:US
Practice Address - Phone:507-377-5493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN093021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical