Provider Demographics
NPI:1225359201
Name:BOLES, SHAWNA E (PSYD)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:E
Last Name:BOLES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 HARVARD STREET
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124
Mailing Address - Country:US
Mailing Address - Phone:617-740-0116
Mailing Address - Fax:413-739-9972
Practice Address - Street 1:425 HARVARD STREET
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124
Practice Address - Country:US
Practice Address - Phone:617-740-0116
Practice Address - Fax:413-739-9972
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MA9700103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical