Healthcare Provider Details

I. General information

NPI: 1588607840
Provider Name (Legal Business Name): JOHN DAVID BOLES LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 PHYLLIS LANE
GREENFIELD MA
01301
US

IV. Provider business mailing address

36 PHYLLIS LANE
GREENFIELD MA
01301
US

V. Phone/Fax

Practice location:
  • Phone: 413-522-2102
  • Fax: 413-772-3724
Mailing address:
  • Phone: 413-522-2102
  • Fax: 413-772-3724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1817
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: