Provider Demographics
NPI:1912376575
Name:BOLES, BRIAN KEITH (WYOMING LPC 1705)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KEITH
Last Name:BOLES
Suffix:
Gender:M
Credentials:WYOMING LPC 1705
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 WILKINS CIR
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-1336
Mailing Address - Country:US
Mailing Address - Phone:307-237-9583
Mailing Address - Fax:307-265-7277
Practice Address - Street 1:1430 WILKINS CIR
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-1336
Practice Address - Country:US
Practice Address - Phone:307-237-9583
Practice Address - Fax:307-265-7277
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1705101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional