Provider Demographics
NPI:1225270630
Name:BOLEN, GENEVA MICHELLE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:GENEVA
Middle Name:MICHELLE
Last Name:BOLEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 STILL HOPES DR
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-7164
Mailing Address - Country:US
Mailing Address - Phone:803-739-5014
Mailing Address - Fax:
Practice Address - Street 1:1 STILL HOPES DR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-7164
Practice Address - Country:US
Practice Address - Phone:803-739-5014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-31
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4484225X00000X
WAOT00004444225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist