Healthcare Provider Details

I. General information

NPI: 1932835618
Provider Name (Legal Business Name): KELLY MINNETTE BOLAND PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL # 3N14
SAINT LOUIS MO
63110-1081
US

IV. Provider business mailing address

1 CHILDRENS PL # 3N14
SAINT LOUIS MO
63110-1081
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6069
  • Fax:
Mailing address:
  • Phone: 314-454-6069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: