MEDICARE: MARY A BOLER LPC, NCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	2001014488	MO

General Provider Information

NPI Number	:	1093749053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY A BOLER LPC, NCC

Provider Business Mailing Address
First Line	:	11191 HIGHWAY 9 N
Second Line	:
City	:	MAMMOTH SPRING
State	:	AR
Zip	:	72554-7097
Country	:	US
Telephone Number	:	870-895-3977
Fax Number	:	870-895-3978

Provider Business Practice Location Address
First Line	:	11191 HIGHWAY 9 N
Second Line	:
City	:	MAMMOTH SPRING
State	:	AR
Zip	:	72554-7097
Country	:	US
Telephone Number	:	870-895-3977
Fax Number	:	870-895-3978

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	07/08/2007

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