Provider Demographics
NPI:1679237663
Name:BOLES, PHYLICIA R
Entity Type:Individual
Prefix:
First Name:PHYLICIA
Middle Name:R
Last Name:BOLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 NATIONAL HWY
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27360-2317
Mailing Address - Country:US
Mailing Address - Phone:912-401-1511
Mailing Address - Fax:
Practice Address - Street 1:1301 NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-2317
Practice Address - Country:US
Practice Address - Phone:336-472-8230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)