Provider Demographics
NPI:1225506900
Name:BOLLAS, SACHA MIRAN
Entity Type:Individual
Prefix:
First Name:SACHA
Middle Name:MIRAN
Last Name:BOLLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3786 BEETHOVEN ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3536
Mailing Address - Country:US
Mailing Address - Phone:310-741-7408
Mailing Address - Fax:
Practice Address - Street 1:1990 S BUNDY DR STE 320
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5249
Practice Address - Country:US
Practice Address - Phone:310-741-7408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-11
Last Update Date:2018-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28063103TB0200X, 103TC2200X, 103TP0814X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis