Healthcare Provider Details

I. General information

NPI: 1225652704
Provider Name (Legal Business Name): SRI PUJA BOLLIGARLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2020
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1463 I94 BUSINESS LOOP E
DICKINSON ND
58601-6434
US

IV. Provider business mailing address

1463 I94 BUSINESS LOOP E
DICKINSON ND
58601-6434
US

V. Phone/Fax

Practice location:
  • Phone: 701-227-7500
  • Fax: 701-227-7575
Mailing address:
  • Phone: 701-227-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2005
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: