Provider Demographics
NPI:1811178122
Name:BOLING, PHYLLIS ELAINE (PSYD)
Entity type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:ELAINE
Last Name:BOLING
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5879 HUNTERS GATE DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-2305
Mailing Address - Country:US
Mailing Address - Phone:248-641-7449
Mailing Address - Fax:
Practice Address - Street 1:38345 W 10 MILE RD
Practice Address - Street 2:150A
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-2867
Practice Address - Country:US
Practice Address - Phone:248-478-0466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013033103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical