Healthcare Provider Details

I. General information

NPI: 1659112175
Provider Name (Legal Business Name): ELAINE GRACE BERGHUIS BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELAINE GRACE OROURKE

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 CENTRE POINTE DR STE 90
ROSEVILLE MN
55113-1112
US

IV. Provider business mailing address

1866 COUNTY ROAD F E
WHITE BEAR LAKE MN
55110-3840
US

V. Phone/Fax

Practice location:
  • Phone: 763-999-8938
  • Fax:
Mailing address:
  • Phone: 612-322-5206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA1120
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: