Provider Demographics
NPI:1386911816
Name:BOLEN, ELIZABETH LARKIN (MSMFT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:LARKIN
Last Name:BOLEN
Suffix:
Gender:F
Credentials:MSMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 N 5TH ST
Mailing Address - Street 2:P1123
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-9559
Mailing Address - Country:US
Mailing Address - Phone:847-254-1663
Mailing Address - Fax:
Practice Address - Street 1:3995 MARCOLA RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-7948
Practice Address - Country:US
Practice Address - Phone:541-747-7734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-29
Last Update Date:2012-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist