Provider Demographics
NPI:1538236039
Name:TOLLEFSON, BARBARA JEAN (MA LP)
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:JEAN
Last Name:TOLLEFSON
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:PO BOX 546
Mailing Address - Street 2:261 E BROADWAY
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-0546
Mailing Address - Country:US
Mailing Address - Phone:763-295-3207
Mailing Address - Fax:763-295-6666
Practice Address - Street 1:261 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-9317
Practice Address - Country:US
Practice Address - Phone:763-295-3207
Practice Address - Fax:763-295-6666
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2285103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN333J5TOOtherINDIV BCBS NUMBER
MN6234967OtherUBH
MN333J4TOOtherBCBS
MN110707OtherUCARE