Provider Demographics
NPI:1164448791
Name:BOLEY, DIANE M (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:M
Last Name:BOLEY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PIKE ST
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-4438
Mailing Address - Country:US
Mailing Address - Phone:406-265-6602
Mailing Address - Fax:406-265-2592
Practice Address - Street 1:15 PIKE ST
Practice Address - Street 2:
Practice Address - City:HAVRE
Practice Address - State:MT
Practice Address - Zip Code:59501-4438
Practice Address - Country:US
Practice Address - Phone:406-265-6602
Practice Address - Fax:406-265-2592
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT888101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000252246Medicaid
MT740393OtherBLUE CROSS & BLUE SHIELD