Provider Demographics
NPI:1144778044
Name:BOLLIG, LAURA (MA, OTR/L)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BOLLIG
Suffix:
Gender:F
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12170 WEDGEWOOD DR NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-6703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1891 STATION PKWY NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3341
Practice Address - Country:US
Practice Address - Phone:763-755-4275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105216225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist