Healthcare Provider Details

I. General information

NPI: 1891933230
Provider Name (Legal Business Name): AMANDA ELIZABETH BOLGREN MS, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2009
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 AMERICAN BLVD E STE 8
BLOOMINGTON MN
55425-1230
US

IV. Provider business mailing address

16782 VON KARMAN AVE STE 11
IRVINE CA
92606-2417
US

V. Phone/Fax

Practice location:
  • Phone: 952-767-2267
  • Fax:
Mailing address:
  • Phone: 619-550-6368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH-272
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBA-23
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: