Provider Demographics
NPI:1609099852
Name:BOLLIN, KEVIN PALMER (MSED LP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:PALMER
Last Name:BOLLIN
Suffix:
Gender:M
Credentials:MSED LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 NW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-2902
Mailing Address - Country:US
Mailing Address - Phone:218-829-3235
Mailing Address - Fax:218-829-1368
Practice Address - Street 1:520 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-2902
Practice Address - Country:US
Practice Address - Phone:218-829-3235
Practice Address - Fax:218-829-1368
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0335103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN672053600Medicaid
MN121238OtherUCARE
MN386G3BOOtherBCBSMN
MN62-50723OtherMEDICA UBH
MN990991045425OtherBHP PREFERRED 1
MNHP55897OtherHEALTH PARTNERS