Provider Demographics
NPI:1568190817
Name:BOLTE, BRIANNA ASHLEY WILSON (MS)
Entity Type:Individual
Prefix:MISS
First Name:BRIANNA
Middle Name:ASHLEY WILSON
Last Name:BOLTE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MISS
Other - First Name:BRIANNA
Other - Middle Name:ASHLEY WILSON
Other - Last Name:BOLTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:1916 W SUNSET AVE STE C
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-5142
Mailing Address - Country:US
Mailing Address - Phone:479-318-2490
Mailing Address - Fax:479-318-2491
Practice Address - Street 1:1916 W SUNSET AVE STE C
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-5142
Practice Address - Country:US
Practice Address - Phone:479-318-2490
Practice Address - Fax:479-318-2491
Is Sole Proprietor?:No
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2207009101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor