1114988607 NPI number — T BOLAND ARNP LMFT PHDC INC

Table of content: (NPI 1114988607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114988607 NPI number — T BOLAND ARNP LMFT PHDC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
T BOLAND ARNP LMFT PHDC INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114988607
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1112 WESTON RD
Provider Second Line Business Mailing Address:
PMB 186
Provider Business Mailing Address City Name:
WESTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-577-0008
Provider Business Mailing Address Fax Number:
954-577-0339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 SW 148TH AVE
Provider Second Line Business Practice Location Address:
STE 130
Provider Business Practice Location Address City Name:
SUNRISE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-577-0008
Provider Business Practice Location Address Fax Number:
954-577-0339
Provider Enumeration Date:
04/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOLAND
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
954-577-0008

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  ARNP1838792 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 106H00000X , with the licence number: MT1542 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0344908900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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