Provider Demographics
NPI:1487179172
Name:BOLEN, TRACIE ANN (LMSW)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:ANN
Last Name:BOLEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 S BO DANIEL PL
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-9038
Mailing Address - Country:US
Mailing Address - Phone:208-284-4269
Mailing Address - Fax:
Practice Address - Street 1:314 BADIOLA ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4389
Practice Address - Country:US
Practice Address - Phone:208-454-8389
Practice Address - Fax:208-454-8404
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-36749104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker