Provider Demographics
NPI:1467858936
Name:BOLEY, FREDERICK DAVID (MA)
Entity type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:DAVID
Last Name:BOLEY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 N BUSINESS ROUTE 5
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-2643
Mailing Address - Country:US
Mailing Address - Phone:573-317-9100
Mailing Address - Fax:
Practice Address - Street 1:741 N BUSINESS ROUTE 5
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-2643
Practice Address - Country:US
Practice Address - Phone:573-317-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014033260101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health