Healthcare Provider Details

I. General information

NPI: 1043247331
Provider Name (Legal Business Name): BRYAN L BOLWAHNN PHD, M.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 10/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GAYVEN DR
BALL LA
71405-4903
US

IV. Provider business mailing address

100 GAYVEN DR
BALL LA
71405-4903
US

V. Phone/Fax

Practice location:
  • Phone: 318-641-0444
  • Fax: 318-641-6118
Mailing address:
  • Phone: 318-641-0444
  • Fax: 318-641-6118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number926MPAP
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: