Basic Information
| Provider Information | |||||||||
| NPI: | 1962489740 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLAND | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 N MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | LOVINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882602830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753966611 | ||||||||
| FaxNumber: | 5753961454 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 WEST TAYLOR | ||||||||
| Address2: | |||||||||
| City: | LOVINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882604023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757390062 | ||||||||
| FaxNumber: | 5753961454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 03/14/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0094461 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 58671005 | 05 | NM | MEDICAID |