Provider Demographics
NPI:1093400293
Name:BOLES, LAURA THORNE (MDIV, BCC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:THORNE
Last Name:BOLES
Suffix:
Gender:F
Credentials:MDIV, BCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:484 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-4518
Mailing Address - Country:US
Mailing Address - Phone:415-672-0307
Mailing Address - Fax:
Practice Address - Street 1:484 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-4518
Practice Address - Country:US
Practice Address - Phone:415-672-0307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral