Provider Demographics
NPI:1922993260
Name:BOLLER, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BOLLER
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 1:1622 PATRIOT DR
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66441-1980
Mailing Address - Country:US
Mailing Address - Phone:785-717-8934
Mailing Address - Fax:
Practice Address - Street 1:1622 PATRIOT DR
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:KS
Practice Address - Zip Code:66441-1980
Practice Address - Country:US
Practice Address - Phone:785-717-8934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-09
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant