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General NPI Number Information
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NPI Number | 1235101635
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Entity Type | Individual
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Provider Name | MYRNA LEE BOLAND PSY.D.
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Gender | Female
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Dates
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Enumeration Date | 02/02/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1169 EASTERN PKWY SUITE 1147
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City | LOUISVILLE
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State | KY
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Zip | 40217-1417
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Country | US
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Telephone | 502-451-9222
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Fax | 502-451-4499
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Provider Business Mailing Address
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Address Line | 612 MARYHILL LN
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City | LOUISVILLE
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State | KY
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Zip | 40207-2120
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Country | US
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Telephone | 502-895-1910
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 640
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 20040412
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License Number State | IN
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