Provider Demographics
NPI:1003523531
Name:BOLEM, SURESH E (LPC)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:E
Last Name:BOLEM
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 REDCEDAR DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068-6604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2640 REDCEDAR DR
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068-6604
Practice Address - Country:US
Practice Address - Phone:972-375-6843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX79033101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional