Provider Demographics
NPI:1881753200
Name:BOLEN, DEWEY LYNN (LCSW)
Entity type:Individual
Prefix:MR
First Name:DEWEY
Middle Name:LYNN
Last Name:BOLEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:MCARTHUR
Mailing Address - State:CA
Mailing Address - Zip Code:96056-0009
Mailing Address - Country:US
Mailing Address - Phone:530-243-2575
Mailing Address - Fax:530-244-9899
Practice Address - Street 1:2469 OLD EUREKA WAY
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0336
Practice Address - Country:US
Practice Address - Phone:530-243-2575
Practice Address - Fax:530-244-9899
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS188631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS18863OtherSTATE LICENSE NUMBER
CAZZZ05064ZMedicare UPIN