Provider Demographics
NPI:1215015789
Name:ELLINGBOE, BONNIE KAY (MA LP)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:KAY
Last Name:ELLINGBOE
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14115 JAMES RD STE 305
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-9417
Mailing Address - Country:US
Mailing Address - Phone:763-575-8086
Mailing Address - Fax:320-774-0415
Practice Address - Street 1:14115 JAMES RD STE 305
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-9417
Practice Address - Country:US
Practice Address - Phone:763-575-8086
Practice Address - Fax:320-774-0415
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN3177103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN926S8ELOtherBCBS
MN402820100Medicaid
MN6254698OtherMEDICARE UBH