Provider Demographics
NPI:1033415468
Name:BOLLINGER, TRACIE LAJUAN (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:MS
First Name:TRACIE
Middle Name:LAJUAN
Last Name:BOLLINGER
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 BURLINGTON ST SE
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-4272
Mailing Address - Country:US
Mailing Address - Phone:701-224-1561
Mailing Address - Fax:701-223-2319
Practice Address - Street 1:509 BURLINGTON ST SE
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-4272
Practice Address - Country:US
Practice Address - Phone:701-224-1561
Practice Address - Fax:701-223-2319
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND644225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist