Provider Demographics
NPI:1679096788
Name:BOLAND, JUSTIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:BOLAND
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4577 NORTHWIND RD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-4531
Mailing Address - Country:US
Mailing Address - Phone:650-303-9102
Mailing Address - Fax:
Practice Address - Street 1:2100 S TRIVIZ DR STE G
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-0601
Practice Address - Country:US
Practice Address - Phone:575-556-1849
Practice Address - Fax:575-532-2030
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2019-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1429103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist