Provider Demographics
NPI:1831532159
Name:BOULEY, ROBERT JOHN (MA, LPCC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:BOULEY
Suffix:
Gender:M
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:7300 147TH ST W STE 204
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7850
Practice Address - Country:US
Practice Address - Phone:952-997-3020
Practice Address - Fax:952-997-3026
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00576101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor