Provider Demographics
NPI:1598195315
Name:BOLLE, PAUL WILLEM (IMF)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:WILLEM
Last Name:BOLLE
Suffix:
Gender:M
Credentials:IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 576
Mailing Address - Street 2:125 SACRAMENTO STREET
Mailing Address - City:RIO VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:94571
Mailing Address - Country:US
Mailing Address - Phone:707-374-5243
Mailing Address - Fax:707-374-5381
Practice Address - Street 1:125 SACRAMENTO STREET
Practice Address - Street 2:
Practice Address - City:RIO VISTA
Practice Address - State:CA
Practice Address - Zip Code:94571
Practice Address - Country:US
Practice Address - Phone:707-374-5243
Practice Address - Fax:707-374-5381
Is Sole Proprietor?:No
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF#56148106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist