Provider Demographics
NPI:1265752513
Name:BOLES, SUSAN E (LPC)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:E
Last Name:BOLES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:E
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:9817 CRAWFORD FARMS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6601
Mailing Address - Country:US
Mailing Address - Phone:817-723-9780
Mailing Address - Fax:
Practice Address - Street 1:9817 CRAWFORD FARMS DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6601
Practice Address - Country:US
Practice Address - Phone:817-723-9780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-09
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63416101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional