Healthcare Provider Details

I. General information

NPI: 1225270630
Provider Name (Legal Business Name): GENEVA MICHELLE BOLEN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2009
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 CHANNEL RD STE 102
LAKE WYLIE SC
29710-6101
US

IV. Provider business mailing address

PO BOX 412313 SUITE 102
BOSTON MA
02241-0001
US

V. Phone/Fax

Practice location:
  • Phone: 803-746-7800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number4484
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: