Provider Demographics
NPI:1497927461
Name:BOLES, STACEY L (MS, CCC-A)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:BOLES
Suffix:
Gender:F
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18000 RIVER AVE
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-8329
Practice Address - Country:US
Practice Address - Phone:317-773-6579
Practice Address - Fax:317-776-4557
Is Sole Proprietor?:No
Enumeration Date:2008-03-30
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002258A237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01027070OtherMEDICARE RR PTAN
INP01027070OtherMEDICARE RR PTAN