Provider Demographics
NPI:1760081897
Name:MARY KATHLEEN BOLLES
Entity Type:Organization
Organization Name:MARY KATHLEEN BOLLES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KATHLEEN
Authorized Official - Last Name:BOLLES
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:512-739-6566
Mailing Address - Street 1:6714 LA CONCHA PASS
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1716
Mailing Address - Country:US
Mailing Address - Phone:512-791-5433
Mailing Address - Fax:
Practice Address - Street 1:5000 BEE CAVES RD STE 106
Practice Address - Street 2:
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-5254
Practice Address - Country:US
Practice Address - Phone:512-791-5433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty