Healthcare Provider Details

I. General information

NPI: 1093749053
Provider Name (Legal Business Name): MARY A BOLER LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY A BEVILLE LPC, NCC

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11191 HIGHWAY 9 N
MAMMOTH SPRING AR
72554-7097
US

IV. Provider business mailing address

11191 HIGHWAY 9 N
MAMMOTH SPRING AR
72554-7097
US

V. Phone/Fax

Practice location:
  • Phone: 870-895-3977
  • Fax: 870-895-3978
Mailing address:
  • Phone: 870-895-3977
  • Fax: 870-895-3978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2001014488
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: