Provider Demographics
NPI:1629100276
Name:ROLLY, DOUGLAS W (LMFT)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:W
Last Name:ROLLY
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:WEED
Mailing Address - State:CA
Mailing Address - Zip Code:96094
Mailing Address - Country:US
Mailing Address - Phone:530-859-3664
Mailing Address - Fax:559-228-1106
Practice Address - Street 1:616 S WEED BLVD
Practice Address - Street 2:
Practice Address - City:WEED
Practice Address - State:CA
Practice Address - Zip Code:96094
Practice Address - Country:US
Practice Address - Phone:530-859-3664
Practice Address - Fax:559-228-1106
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT36040106H00000X
CAMFC 36040106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist