Provider Demographics
NPI:1477863710
Name:BOLELLA, ASHLEY (LCSW)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:BOLELLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:DESILET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:169 CANDLEWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06088-9750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:836 FARMINGTON AVE
Practice Address - Street 2:SUITE 221
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119
Practice Address - Country:US
Practice Address - Phone:860-986-6865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1300881Medicaid