Provider Demographics
NPI:1427617133
Name:BOLAND, SHELLY D (LMSW)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:D
Last Name:BOLAND
Suffix:
Gender:F
Credentials:LMSW
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 179
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-0179
Mailing Address - Country:US
Mailing Address - Phone:918-967-3368
Mailing Address - Fax:918-967-4582
Practice Address - Street 1:111 W FORREST AVE STE A
Practice Address - Street 2:
Practice Address - City:EUFAULA
Practice Address - State:OK
Practice Address - Zip Code:74432-3205
Practice Address - Country:US
Practice Address - Phone:918-689-3333
Practice Address - Fax:918-967-4582
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6412104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker