Provider Demographics
NPI:1881888717
Name:BOLAND, JOSEPH D (LCSW)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:D
Last Name:BOLAND
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 1:2527 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-2526
Mailing Address - Country:US
Mailing Address - Phone:406-866-0981
Mailing Address - Fax:
Practice Address - Street 1:2527 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-2526
Practice Address - Country:US
Practice Address - Phone:406-866-0981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT503Medicaid