Provider Demographics
NPI:1851642094
Name:VAN BOLHUIS, IEKTJE (PHD)
Entity Type:Individual
Prefix:DR
First Name:IEKTJE
Middle Name:
Last Name:VAN BOLHUIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:IEKTJE
Other - Middle Name:
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:6012 W WILLIAM CANNON DR
Mailing Address - Street 2:STE B-103
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1980
Mailing Address - Country:US
Mailing Address - Phone:512-891-1500
Mailing Address - Fax:
Practice Address - Street 1:6012 W WILLIAM CANNON DR
Practice Address - Street 2:STE B-103
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1980
Practice Address - Country:US
Practice Address - Phone:512-891-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36265103T00000X
TX70154103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool