Basic Information
| Provider Information | |||||||||
| NPI: | 1023200466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLEN | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 WEST HILL BLVD | ||||||||
| Address2: | 437TH MEDICAL GROUP/SGOH | ||||||||
| City: | CHARLESTON AFB | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294044704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439636972 | ||||||||
| FaxNumber: | 8439636930 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 WEST HILL BLVD. | ||||||||
| Address2: | 437TH MEDICAL GROUP/SGOH | ||||||||
| City: | CHARLESTON AFB | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294044704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439636972 | ||||||||
| FaxNumber: | 8439636930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2007 | ||||||||
| LastUpdateDate: | 09/13/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 20642 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.