MEDICARE: MELISSA BOLEN LMFT

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	106H00000X	Marriage & Family Therapist	MT2711	FL

General Provider Information

NPI Number	:	1528317773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA BOLEN LMFT

Provider Business Mailing Address
First Line	:	950 SW GREENVILLE HILLS RD
Second Line	:
City	:	GREENVILLE
State	:	FL
Zip	:	32331-3108
Country	:	US
Telephone Number	:	850-948-4220
Fax Number	:	850-948-4227

Provider Business Practice Location Address
First Line	:	950 SW GREENVILLE HILLS RD
Second Line	:
City	:	GREENVILLE
State	:	FL
Zip	:	32331-3108
Country	:	US
Telephone Number	:	850-948-4220
Fax Number	:	850-948-4227

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

Provider Enumeration Date	:	09/04/2012
Last Update Date	:	09/04/2012

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