Provider Demographics
NPI:1174633788
Name:BOLL, LARRY A (PHD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:A
Last Name:BOLL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S WHITTIER ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-1048
Mailing Address - Country:US
Mailing Address - Phone:316-689-4220
Mailing Address - Fax:316-689-4221
Practice Address - Street 1:111 S WHITTIER ST
Practice Address - Street 2:SUITE 305
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-1048
Practice Address - Country:US
Practice Address - Phone:316-689-4220
Practice Address - Fax:316-689-4221
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS288103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS007049OtherBC/BS
KS007049OtherBC/BS