Provider Demographics
NPI:1962614032
Name:BURGGRAFF, BETHANI J (MS, BCBA)
Entity type:Individual
Prefix:
First Name:BETHANI
Middle Name:J
Last Name:BURGGRAFF
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11150 PHEASANT LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7634
Mailing Address - Country:US
Mailing Address - Phone:612-210-0567
Mailing Address - Fax:
Practice Address - Street 1:2925 DEAN PKWY STE 300
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-7700
Practice Address - Country:US
Practice Address - Phone:612-925-8366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-05-2536174400000X
MN1-05-2536103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist