Provider Demographics
NPI:1124453881
Name:SCOTT-BOLLER, JOHNNIE
Entity type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:
Last Name:SCOTT-BOLLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOHNNIE
Other - Middle Name:
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:445 31ST ST N
Mailing Address - Street 2:ST. PETERSBURG
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-7605
Mailing Address - Country:US
Mailing Address - Phone:727-328-4008
Mailing Address - Fax:727-545-7590
Practice Address - Street 1:445 31ST ST N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-7605
Practice Address - Country:US
Practice Address - Phone:727-328-4008
Practice Address - Fax:727-258-9120
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health