Healthcare Provider Details

I. General information

NPI: 1114074028
Provider Name (Legal Business Name): MELISSA ANN BOLLINGER-KINNEY M.S.ED LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 10/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 HARBOR LN N STE 206
PLYMOUTH MN
55447-5120
US

IV. Provider business mailing address

6369 POLARIS LN N
MAPLE GROVE MN
55311-3938
US

V. Phone/Fax

Practice location:
  • Phone: 763-559-1640
  • Fax: 763-559-1617
Mailing address:
  • Phone: 612-508-7115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number226
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: