=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760081897
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARY KATHLEEN BOLLES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2020
-----------------------------------------------------
Last Update Date | 10/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5000 BEE CAVES RD STE 106
-----------------------------------------------------
City | WEST LAKE HILLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78746-5254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-791-5433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6714 LA CONCHA PASS
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78749-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-791-5433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARY KATHLEEN BOLLES
-----------------------------------------------------
Credential | PMHNP
-----------------------------------------------------
Telephone | 512-739-6566
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------