Provider Demographics
NPI:1477953842
Name:BOLEN, LIANA
Entity type:Individual
Prefix:
First Name:LIANA
Middle Name:
Last Name:BOLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 SAGE LN
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:ME
Mailing Address - Zip Code:04027-3863
Mailing Address - Country:US
Mailing Address - Phone:214-770-1306
Mailing Address - Fax:
Practice Address - Street 1:29 SAGE LN
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:ME
Practice Address - Zip Code:04027-3863
Practice Address - Country:US
Practice Address - Phone:214-770-1306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1-18-31079103K00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist