Provider Demographics
NPI:1932576725
Name:BOLEY, MATTHEW (MS, LPC, CDCA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BOLEY
Suffix:
Gender:M
Credentials:MS, LPC, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-2323
Mailing Address - Country:US
Mailing Address - Phone:567-279-4829
Mailing Address - Fax:
Practice Address - Street 1:5100 FAIRGROUND RD
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-9775
Practice Address - Country:US
Practice Address - Phone:419-586-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH120235101YA0400X
OH1300195101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1300195OtherOHIO COUNSELOR SOCIAL WORK MARRIAGE FAMILY THERAPY BOARD-LPC NUMBER
OH120235OtherOHIO CHEMICAL DEPENDENCY PROFESSIONALS BOARD-CDCA NUMBER