MEDICARE: BOLLICH, LLC

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	103G00000X	Clinical Neuropsychologist	04336	MD

General Provider Information

NPI Number	:	1750635231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOLLICH, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1633
Second Line	:
City	:	PRINCE FREDERICK
State	:	MD
Zip	:	20678-1633
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	65 DUKE ST STE 111
Second Line	:
City	:	PRINCE FREDERICK
State	:	MD
Zip	:	20678-6128
Country	:	US
Telephone Number	:	301-448-9283
Fax Number	:

Authorized Official
Title or Position	:	NEUROPSYCHOLOGIST
Name	:	DR. ANGELA MARIE BOLLICH
Credential	:	PH.D.
Telephone Number	:	301-448-9283

Provider Enumeration Date	:	11/05/2012
Last Update Date	:	11/05/2012

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