Healthcare Provider Details

I. General information

NPI: 1124037957
Provider Name (Legal Business Name): MARY KATHLEEN BOLLES PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 10/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3705 MEDICAL PARKWAY, #450 AUSTIN MEDICAL PLAZA
AUSTIN TX
78705
US

IV. Provider business mailing address

3705 MEDICAL PARKWAY #450 AUSTIN MEDICAL PLAZA
AUSTIN TX
78705
US

V. Phone/Fax

Practice location:
  • Phone: 512-306-0061
  • Fax: 512-306-0069
Mailing address:
  • Phone: 512-306-0061
  • Fax: 512-306-0069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number13337
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number521247
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number521247
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: