Provider Demographics
NPI:1942241658
Name:BOLHOUSE, LISA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:BOLHOUSE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4996 BRANDED OAKS CT
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-8834
Mailing Address - Country:US
Mailing Address - Phone:239-851-2332
Mailing Address - Fax:850-765-5487
Practice Address - Street 1:109 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-6152
Practice Address - Country:US
Practice Address - Phone:850-443-8977
Practice Address - Fax:850-765-5487
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW18721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ2591Medicare ID - Type Unspecified