Provider Demographics
NPI:1003331968
Name:BOLEY, DALTON (LCSW)
Entity Type:Individual
Prefix:
First Name:DALTON
Middle Name:
Last Name:BOLEY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 E FORT UNION BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-5531
Mailing Address - Country:US
Mailing Address - Phone:801-984-1717
Mailing Address - Fax:
Practice Address - Street 1:150 S 400 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2510
Practice Address - Country:US
Practice Address - Phone:801-984-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 1041S0200X
UT10246784-3503171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator