Healthcare Provider Details

I. General information

NPI: 1477953842
Provider Name (Legal Business Name): LIANA BOLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 SAGE LN
LEBANON ME
04027-3863
US

IV. Provider business mailing address

29 SAGE LN
LEBANON ME
04027-3863
US

V. Phone/Fax

Practice location:
  • Phone: 214-770-1306
  • Fax:
Mailing address:
  • Phone: 214-770-1306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-18-31079
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: