Provider Demographics
NPI:1386927333
Name:BOLSTROM, CHAD (LPCC)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:BOLSTROM
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3137 HENNEPIN AVE
Mailing Address - Street 2:# 202
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2601
Mailing Address - Country:US
Mailing Address - Phone:612-208-3294
Mailing Address - Fax:
Practice Address - Street 1:3137 HENNEPIN AVE
Practice Address - Street 2:# 202
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2601
Practice Address - Country:US
Practice Address - Phone:612-208-3294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00313101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional