Provider Demographics
NPI:1619009206
Name:BOLES, THOMAS EDGERTON (LPC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:EDGERTON
Last Name:BOLES
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 S MANGUM ST
Mailing Address - Street 2:731 MILLSPRING DRIVE
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-3618
Mailing Address - Country:US
Mailing Address - Phone:919-560-0975
Mailing Address - Fax:
Practice Address - Street 1:219 S MANGUM ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-3618
Practice Address - Country:US
Practice Address - Phone:919-560-0975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5068101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional