Provider Demographics
NPI:1336285105
Name:BOLEN, SCOTT C (QMHA)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:C
Last Name:BOLEN
Suffix:
Gender:M
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3431 N ARLINGTON PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-7205
Mailing Address - Country:US
Mailing Address - Phone:503-231-8948
Mailing Address - Fax:
Practice Address - Street 1:3909 SE 70TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-2525
Practice Address - Country:US
Practice Address - Phone:503-777-2278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR171M00000XOtherQ.M.H.A.