Provider Demographics
NPI:1235788308
Name:BOLLES, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BOLLES
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 1:2275 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1132
Mailing Address - Country:US
Mailing Address - Phone:510-317-1444
Mailing Address - Fax:
Practice Address - Street 1:111 SMITH RANCH RD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1939
Practice Address - Country:US
Practice Address - Phone:415-250-6597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA116963106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist