Provider Demographics
NPI:1578696944
Name:BOLLING, LANNY CLARICE (PSYD)
Entity Type:Individual
Prefix:
First Name:LANNY
Middle Name:CLARICE
Last Name:BOLLING
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MS
Other - First Name:LANNY
Other - Middle Name:CLARICE
Other - Last Name:BOLLING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:108 W SUMMIT HILL DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37902-1025
Mailing Address - Country:US
Mailing Address - Phone:865-525-1099
Mailing Address - Fax:865-525-7494
Practice Address - Street 1:101 MED TECH PKWY STE 200
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4001
Practice Address - Country:US
Practice Address - Phone:423-232-6120
Practice Address - Fax:423-232-6125
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP2824103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I681458OtherMEDICARE PROVIDER TRANSACTION ACCESS NUMBER (PTAN)