Provider Demographics
NPI:1841763141
Name:BOLEN, BRANT ANDREW (CDCA)
Entity type:Individual
Prefix:MR
First Name:BRANT
Middle Name:ANDREW
Last Name:BOLEN
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 N BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-2827
Mailing Address - Country:US
Mailing Address - Phone:330-553-4545
Mailing Address - Fax:
Practice Address - Street 1:1319 FLORENCEDALE AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-2719
Practice Address - Country:US
Practice Address - Phone:330-553-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH169193101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)