Basic Information
| Provider Information | |||||||||
| NPI: | 1649819665 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KALSTABAKKEN | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | WENZEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2512 S 7TH ST | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554541404 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2512 S 7TH ST | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554541404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123656777 | ||||||||
| FaxNumber: | 6123658001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2019 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | LP6427 | MN | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.