Basic Information
| Provider Information | |||||||||
| NPI: | 1891933230 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLGREN | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | MS, BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16782 VON KARMAN AVE STE 11 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926062417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195506368 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1801 AMERICAN BLVD E STE 8 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554251230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9527672267 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2009 | ||||||||
| LastUpdateDate: | 03/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH-272 | HI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103K00000X | MN | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | BA-23 | HI | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-15-19783 | 01 | BCBA CERTIFICATE | OTHER |