Provider Demographics
NPI:1528162625
Name:BOLANDER, TRACI (PSYD)
Entity type:Individual
Prefix:DR
First Name:TRACI
Middle Name:
Last Name:BOLANDER
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 1:910 S CHAPEL ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-3467
Mailing Address - Country:US
Mailing Address - Phone:302-224-1400
Mailing Address - Fax:302-224-1402
Practice Address - Street 1:910 S CHAPEL ST
Practice Address - Street 2:SUITE 102
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-3467
Practice Address - Country:US
Practice Address - Phone:302-224-1400
Practice Address - Fax:302-224-1402
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB1-0000724103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE492154Medicare PIN
DEG02735M01Medicare PIN