Provider Demographics
NPI:1851942171
Name:BOLES, SHANEKA R (P-LPC)
Entity Type:Individual
Prefix:
First Name:SHANEKA
Middle Name:R
Last Name:BOLES
Suffix:
Gender:F
Credentials:P-LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 HIGHWAY 80 W STE R
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-4108
Mailing Address - Country:US
Mailing Address - Phone:601-473-2106
Mailing Address - Fax:
Practice Address - Street 1:604 HIGHWAY 80 W STE R
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4108
Practice Address - Country:US
Practice Address - Phone:601-473-2106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-27
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-0714171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator