Provider Demographics
NPI:1124037957
Name:BOLLES, MARY KATHLEEN (PMHNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHLEEN
Last Name:BOLLES
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3705 MEDICAL PARKWAY #450
Mailing Address - Street 2:AUSTIN MEDICAL PLAZA
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705
Mailing Address - Country:US
Mailing Address - Phone:512-306-0061
Mailing Address - Fax:512-306-0069
Practice Address - Street 1:3705 MEDICAL PARKWAY, #450
Practice Address - Street 2:AUSTIN MEDICAL PLAZA
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705
Practice Address - Country:US
Practice Address - Phone:512-306-0061
Practice Address - Fax:512-306-0069
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13337101YA0400X
TX521247163WP0809X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult