Provider Demographics
NPI:1154330975
Name:BOLEN, MICHELLE H (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:H
Last Name:BOLEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 ROOSEVELT TRL STE 302A
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-5281
Mailing Address - Country:US
Mailing Address - Phone:207-892-7797
Mailing Address - Fax:207-892-7797
Practice Address - Street 1:744 ROOSEVELT TRL STE 302A
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-5281
Practice Address - Country:US
Practice Address - Phone:207-892-7797
Practice Address - Fax:207-892-7797
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC44441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM388501Medicare PIN
MEMM3885Medicare PIN