Healthcare Provider Details

I. General information

NPI: 1235329251
Provider Name (Legal Business Name): BOLESKY INTENTION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 GRAVITY WAY
BUCKLEY WA
98321-9587
US

IV. Provider business mailing address

730 GRAVITY WAY
BUCKLEY WA
98321-9587
US

V. Phone/Fax

Practice location:
  • Phone: 360-829-1025
  • Fax: 360-829-2805
Mailing address:
  • Phone: 360-829-1025
  • Fax: 360-829-2805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH00004290
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00004219
License Number StateWA

VIII. Authorized Official

Name: MS. KAREN L BOLESKY
Title or Position: OWNER PRESIDENT CORP
Credential: LMHC LMP
Phone: 360-829-1025