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NPI Code Detail

MEDICARE: MR. MICHAEL BOLAND

MEDICARE: MR. MICHAEL BOLAND
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
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1891101861
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. MICHAEL BOLAND
Provider Business Mailing Address
First Line : 4220 N GRAND BLVD
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63107-1831
Country : US
Telephone Number : 314-534-6624
Fax Number : 341-535-4394
Provider Business Practice Location Address
First Line : 4220 N GRAND BLVD
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63107-1831
Country : US
Telephone Number : 314-534-6624
Fax Number : 341-535-4394
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/10/2014
Last Update Date : 07/10/2014

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