Provider Demographics
NPI:1669980439
Name:BOLLES, TAMMY M (LCSW)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:M
Last Name:BOLLES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 OLD RIVER TRL
Mailing Address - Street 2:
Mailing Address - City:CHULUOTA
Mailing Address - State:FL
Mailing Address - Zip Code:32766-8603
Mailing Address - Country:US
Mailing Address - Phone:305-781-1682
Mailing Address - Fax:
Practice Address - Street 1:1708 OLD RIVER TRL.
Practice Address - Street 2:
Practice Address - City:CHULUOTA
Practice Address - State:FL
Practice Address - Zip Code:32766-3276
Practice Address - Country:US
Practice Address - Phone:305-781-1682
Practice Address - Fax:305-781-1682
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW135851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical