Provider Demographics
NPI:1356677421
Name:BOLEN, BRIAN KEITH (PSY D, LMHC)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KEITH
Last Name:BOLEN
Suffix:
Gender:M
Credentials:PSY D, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4651 WANDERING WAY
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-8500
Mailing Address - Country:US
Mailing Address - Phone:813-907-0285
Mailing Address - Fax:813-406-5158
Practice Address - Street 1:3903 NORTHDALE BLVD STE 100-47
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-1864
Practice Address - Country:US
Practice Address - Phone:813-817-8498
Practice Address - Fax:813-406-5158
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-26
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8545101YM0800X
FLCAP 2482101YA0400X
101YM0800X
FLMH 8545101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)