Provider Demographics
NPI:1801194121
Name:BOLAND, BARBARA (LMP)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:BOLAND
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 CRESTLINE CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-6704
Mailing Address - Country:US
Mailing Address - Phone:208-798-0128
Mailing Address - Fax:
Practice Address - Street 1:1114 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1902
Practice Address - Country:US
Practice Address - Phone:208-743-1974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID08-002391225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist