Provider Demographics
NPI:1568647881
Name:BOLLES, MARJORIE (RN, LCPC)
Entity Type:Individual
Prefix:MRS
First Name:MARJORIE
Middle Name:
Last Name:BOLLES
Suffix:
Gender:F
Credentials:RN, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4696 W OVERLAND RD
Mailing Address - Street 2:268
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2845
Mailing Address - Country:US
Mailing Address - Phone:208-383-0072
Mailing Address - Fax:
Practice Address - Street 1:4696 W OVERLAND RD
Practice Address - Street 2:268
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2845
Practice Address - Country:US
Practice Address - Phone:208-383-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-05
Last Update Date:2008-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health