MEDICARE: DR. PHYLLIS LYNN BOLLING PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	366I00342000	NJ

General Provider Information

NPI Number	:	1225469943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHYLLIS LYNN BOLLING PH.D.

Provider Business Mailing Address
First Line	:	P.O. BOX 3022
Second Line	:
City	:	WEST ORANGE
State	:	NJ
Zip	:	07102
Country	:	US
Telephone Number	:	973-677-1148
Fax Number	:

Provider Business Practice Location Address
First Line	:	2816 MORRIS AVE
Second Line	:	SUITE 22
City	:	UNION
State	:	NJ
Zip	:	07083-4849
Country	:	US
Telephone Number	:	973-677-1148
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2013
Last Update Date	:	12/05/2013

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