Provider Demographics
NPI:1043247331
Name:BOLWAHNN, BRYAN L (PHD, MP)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:L
Last Name:BOLWAHNN
Suffix:
Gender:M
Credentials:PHD, MP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GAYVEN DR
Mailing Address - Street 2:
Mailing Address - City:BALL
Mailing Address - State:LA
Mailing Address - Zip Code:71405-4903
Mailing Address - Country:US
Mailing Address - Phone:318-641-0444
Mailing Address - Fax:318-641-6118
Practice Address - Street 1:100 GAYVEN DR
Practice Address - Street 2:
Practice Address - City:BALL
Practice Address - State:LA
Practice Address - Zip Code:71405-4903
Practice Address - Country:US
Practice Address - Phone:318-641-0444
Practice Address - Fax:318-641-6118
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA926MPAP103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)