Healthcare Provider Details

I. General information

NPI: 1356303127
Provider Name (Legal Business Name): MARY ANGELA BOLAND LCP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1657 MERRIMAC TRL
WILLIAMSBURG VA
23185-5624
US

IV. Provider business mailing address

1657 MERRIMAC TRL
WILLIAMSBURG VA
23185-5624
US

V. Phone/Fax

Practice location:
  • Phone: 757-220-3200
  • Fax: 757-253-4371
Mailing address:
  • Phone: 757-220-3200
  • Fax: 757-253-4371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810003602
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: