Provider Demographics
NPI:1093749053
Name:BOLER, MARY A (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:BOLER
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:BEVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC, NCC
Mailing Address - Street 1:11191 HIGHWAY 9 N
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH SPRING
Mailing Address - State:AR
Mailing Address - Zip Code:72554-7097
Mailing Address - Country:US
Mailing Address - Phone:870-895-3977
Mailing Address - Fax:870-895-3978
Practice Address - Street 1:11191 HIGHWAY 9 N
Practice Address - Street 2:
Practice Address - City:MAMMOTH SPRING
Practice Address - State:AR
Practice Address - Zip Code:72554-7097
Practice Address - Country:US
Practice Address - Phone:870-895-3977
Practice Address - Fax:870-895-3978
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001014488101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional