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General NPI Number Information
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NPI Number | 1982333118
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Entity Type | Individual
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Provider Name | GRETTA BOLSTAD
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Gender | Female
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Dates
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Enumeration Date | 06/04/2022
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Last Update Date | 06/20/2022
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Provider Practice Location Address
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Address Line | 4201 DEAN LAKES BLVD
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City | SHAKOPEE
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State | MN
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Zip | 55379-2829
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Country | US
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Telephone | 612-416-1301
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Fax |
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Provider Business Mailing Address
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Address Line | 19151 BROOKWOOD RD
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City | PRIOR LAKE
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State | MN
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Zip | 55372-9740
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 247200000X
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Taxonomy Name | Other Technician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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