Organization
BAMBOO COUNSELING SERVICES PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
REGINA HOLLIBUSH LICSW (OUTPATIENT MENTAL HEALTH THERAPIST)
(651) 243-8967
Entity
Organization
Contact information
Practice address
12295 LAKE BLVD, LINDSTROM, MN 55045-9325
(651) 243-8967
Mailing address
12295 LAKE BLVD, LINDSTROM, MN 55045-9325
(651) 243-8967
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
18910
MN
251S00000X
Community/Behavioral Health Agency
6925
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1396910022
—
MN
01
—
800002086
MEDICARE NUMBER; NOT SURE WHICH IDENTIFIER
MN
Enumeration date
11/10/2016
Last updated
11/10/2016
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