Healthcare Provider Details

I. General information

NPI: 1760998728
Provider Name (Legal Business Name): SHELBY KRISTINE BOLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 TRACY AVE
VAN METER IA
50261-6204
US

IV. Provider business mailing address

2675 TRACY AVE
VAN METER IA
50261-6204
US

V. Phone/Fax

Practice location:
  • Phone: 816-509-0890
  • Fax:
Mailing address:
  • Phone: 816-509-0890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number136091
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2017022231
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: