Provider Demographics
NPI:1801403464
Name:BOLLEY, DEMI LYNN
Entity Type:Individual
Prefix:
First Name:DEMI
Middle Name:LYNN
Last Name:BOLLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 SAGE GLEN DR
Mailing Address - Street 2:
Mailing Address - City:SPRING CREEK
Mailing Address - State:NV
Mailing Address - Zip Code:89815-5738
Mailing Address - Country:US
Mailing Address - Phone:775-397-0586
Mailing Address - Fax:
Practice Address - Street 1:1250 LAMOILLE HWY STE 103
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-4397
Practice Address - Country:US
Practice Address - Phone:775-777-1292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT1349106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician