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General NPI Number Information
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NPI Number | 1437691128
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Entity Type | Organization
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Legal Business Name | BAMBOO COUNSELING SERVICES PLLC
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Dates
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Enumeration Date | 11/10/2016
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Last Update Date | 11/10/2016
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Provider Practice Location Address
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Address Line | 12295 LAKE BLVD
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City | LINDSTROM
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State | MN
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Zip | 55045-9325
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Country | US
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Telephone | 651-243-8967
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Fax |
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Provider Business Mailing Address
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Address Line | 12295 LAKE BLVD
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City | LINDSTROM
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State | MN
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Zip | 55045-9325
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Country | US
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Telephone | 651-243-8967
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Fax |
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Authorized Official
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Title or Position | OUTPATIENT MENTAL HEALTH THERAPIST
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Name | REGINA HOLLIBUSH
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Credential | LICSW
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Telephone | 651-243-8967
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 6925
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 18910
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License Number State | MN
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