Provider Demographics
NPI:1104183854
Name:BOLEN, AMANDA JANE (MA, LGPC)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:JANE
Last Name:BOLEN
Suffix:
Gender:F
Credentials:MA, LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 S MAIN ST BLDG A
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-5447
Mailing Address - Country:US
Mailing Address - Phone:410-914-4012
Mailing Address - Fax:
Practice Address - Street 1:1804 LARKIN PL
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-4885
Practice Address - Country:US
Practice Address - Phone:443-910-0612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP3491101YP2500X
MDLC4827101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional