Provider Demographics
NPI:1508222837
Name:LORETTA L. BOLYARD, PHD, PC
Entity Type:Organization
Organization Name:LORETTA L. BOLYARD, PHD, PC
Other - Org Name:LORETTA L. BOLYARD, PHD
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BOLYARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:406-210-9801
Mailing Address - Street 1:125 W GRANITE ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-9215
Mailing Address - Country:US
Mailing Address - Phone:406-210-9801
Mailing Address - Fax:406-723-5406
Practice Address - Street 1:125 W GRANITE ST
Practice Address - Street 2:SUITE 207
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-9215
Practice Address - Country:US
Practice Address - Phone:406-210-9801
Practice Address - Fax:406-723-5406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1479103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty