Provider Demographics
NPI:1710026331
Name:BOLLINGER, KERRI L (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:KERRI
Middle Name:L
Last Name:BOLLINGER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3604 QUAY ROAD 63.5
Mailing Address - Street 2:
Mailing Address - City:TUCUMCARI
Mailing Address - State:NM
Mailing Address - Zip Code:88401-9627
Mailing Address - Country:US
Mailing Address - Phone:505-461-3309
Mailing Address - Fax:
Practice Address - Street 1:1701 S 11TH ST
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-3715
Practice Address - Country:US
Practice Address - Phone:505-461-4344
Practice Address - Fax:505-461-8033
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-063461041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM94026556Medicaid