Basic Information
| Provider Information | |||||||||
| NPI: | 1215015789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLINGBOE | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14115 JAMES RD STE 305 | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553749417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635758086 | ||||||||
| FaxNumber: | 3207740415 | ||||||||
| Practice Location | |||||||||
| Address1: | 14115 JAMES RD STE 305 | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553749417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635758086 | ||||||||
| FaxNumber: | 3207740415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 05/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | MN3177 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 926S8EL | 01 | MN | BCBS | OTHER | 402820100 | 05 | MN | MEDICAID | 6254698 | 01 | MN | MEDICARE UBH | OTHER |