Provider Demographics
NPI:1770703431
Name:BOLAN, THOMAS S (LCSW, CSAC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:BOLAN
Suffix:
Gender:
Credentials:LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 LAURA LN STE 120
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-1428
Mailing Address - Country:US
Mailing Address - Phone:608-752-2930
Mailing Address - Fax:
Practice Address - Street 1:3207 LAURA LN STE 100
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-1428
Practice Address - Country:US
Practice Address - Phone:608-290-0956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15382-132101YA0400X
WI8420-123101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health