Provider Demographics
NPI:1689619215
Name:BOLYARD, KATHERINE L (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:L
Last Name:BOLYARD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 N 18TH ST
Mailing Address - Street 2:STE 1
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2288
Mailing Address - Country:US
Mailing Address - Phone:765-447-7146
Mailing Address - Fax:765-447-4932
Practice Address - Street 1:911 N 18TH ST
Practice Address - Street 2:STE 1
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2288
Practice Address - Country:US
Practice Address - Phone:765-447-7146
Practice Address - Fax:765-447-4932
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-18
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041188A103TA0700X, 103TC1900X, 103TP2701X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200186570AMedicaid