Individual
HEATHER BODURTHA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1900 SILVER LAKE RD NW, 110, NEW BRIGHTON, MN 55112-1786
(651) 628-9566
Mailing address
1900 SILVER LAKE RD NW, 110, NEW BRIGHTON, MN 55112-1786
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
LP4705
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
652660100
—
MN
Enumeration date
05/29/2007
Last updated
10/10/2012
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