Healthcare Provider Details

I. General information

NPI: 1871283069
Provider Name (Legal Business Name): LINDSAY BOLLA ASSOCIATE MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LINDSAY JOY BOLLA JACOBS

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1523 LONGBRANCH AVE
GROVER BEACH CA
93433-2508
US

IV. Provider business mailing address

PO BOX 14242
SAN LUIS OBISPO CA
93406-4242
US

V. Phone/Fax

Practice location:
  • Phone: 805-473-7080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number163540
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: