Provider Demographics
NPI:1063384295
Name:GULSTAD, ANNALISE
Entity type:Individual
Prefix:
First Name:ANNALISE
Middle Name:
Last Name:GULSTAD
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 1:621 W LAKE ST STE 350
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2952
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3033 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4688
Practice Address - Country:US
Practice Address - Phone:612-979-2276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-18
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC05199101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health