Provider Demographics
NPI:1013803253
Name:MBOLLE, IMMACULATE
Entity type:Individual
Prefix:MS
First Name:IMMACULATE
Middle Name:
Last Name:MBOLLE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:IMMACULATE
Other - Middle Name:
Other - Last Name:MBOLLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11404 STEWART LN
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-2216
Mailing Address - Country:US
Mailing Address - Phone:301-442-7512
Mailing Address - Fax:
Practice Address - Street 1:6911 LAUREL BOWIE RD STE 309
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-1712
Practice Address - Country:US
Practice Address - Phone:301-755-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician