Provider Demographics
NPI:1275640013
Name:BOLEN, BETH
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:BOLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:FORTUNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:608 W HAYS, SUITE 200
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-2612
Mailing Address - Country:US
Mailing Address - Phone:208-381-7312
Mailing Address - Fax:208-381-7313
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-381-2222
Practice Address - Fax:208-381-8749
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health