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General NPI Number Information
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NPI Number | 1396125514
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Entity Type | Organization
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Legal Business Name | LISA BOLHOUSE
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Dates
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Enumeration Date | 06/03/2015
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Last Update Date | 06/03/2015
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Provider Practice Location Address
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Address Line | 109 W 4TH AVE
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City | TALLAHASSEE
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State | FL
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Zip | 32303-6152
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Country | US
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Telephone | 850-443-8977
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Fax | 850-765-5487
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Provider Business Mailing Address
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Address Line | 4996 BRANDED OAKS CT
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City | TALLAHASSEE
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State | FL
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Zip | 32311-8834
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Country | US
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Telephone | 850-443-8977
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Fax | 850-765-5487
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Authorized Official
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Title or Position | OWNER, PRIVATE PRACTICE
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Name | LISA MARIE BOLHOUSE
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Credential | LCSW
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Telephone | 850-443-8977
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | SW1872
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License Number State | FL
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