Provider Demographics
NPI:1922772383
Name:INGVALDSON, BRITTNI AMANDA
Entity type:Individual
Prefix:
First Name:BRITTNI
Middle Name:AMANDA
Last Name:INGVALDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5241 LINCOLN DR APT 113
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-2701
Mailing Address - Country:US
Mailing Address - Phone:507-363-1672
Mailing Address - Fax:
Practice Address - Street 1:17645 JUNIPER PATH STE 105
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-7491
Practice Address - Country:US
Practice Address - Phone:952-600-8191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-08
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN04654101YP2500X
MN304240101YA0400X
MN102X00000X, 221700000X, 261QM0801X, 261QM0850X, 261QM0855X, 261QS1000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No102X00000XBehavioral Health & Social Service ProvidersPoetry TherapistGroup - Multi-Specialty
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent HealthGroup - Multi-Specialty