Provider Demographics
NPI:1326529306
Name:BOLSEN, KATHERINE A (HSPP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:A
Last Name:BOLSEN
Suffix:
Gender:F
Credentials:HSPP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:EARL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:415 N 26TH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2895
Mailing Address - Country:US
Mailing Address - Phone:765-446-6535
Mailing Address - Fax:765-446-3536
Practice Address - Street 1:415 N 26TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2895
Practice Address - Country:US
Practice Address - Phone:765-446-6535
Practice Address - Fax:765-446-3536
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INPENDING103T00000X, 103TH0100X
IN20043271A103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103T00000XBehavioral Health & Social Service ProvidersPsychologist