Provider Demographics
NPI:1962707950
Name:FLECKENSTEIN, PAUL GREGORY
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:GREGORY
Last Name:FLECKENSTEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55807-1563
Mailing Address - Country:US
Mailing Address - Phone:218-628-0237
Mailing Address - Fax:651-323-2184
Practice Address - Street 1:4000 W 9TH ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-1563
Practice Address - Country:US
Practice Address - Phone:218-628-0237
Practice Address - Fax:651-323-2184
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2221-1231041C0700X
WI1000-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical