Provider Demographics
NPI:1003092214
Name:LEAN ON ME THERAPY
Entity Type:Organization
Organization Name:LEAN ON ME THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOHLKEN
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:563-581-2673
Mailing Address - Street 1:500 OAKHURST DR., APT. 6
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-3619
Mailing Address - Country:US
Mailing Address - Phone:563-581-2673
Mailing Address - Fax:
Practice Address - Street 1:500 OAKHURST DR., APT. 6
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-3619
Practice Address - Country:US
Practice Address - Phone:563-581-2673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06264251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0201259Medicaid