Provider Demographics
NPI:1932532793
Name:BOLEN, MARK WESLEY (MSE, LPC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WESLEY
Last Name:BOLEN
Suffix:
Gender:M
Credentials:MSE, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 E AYER ST
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-2202
Mailing Address - Country:US
Mailing Address - Phone:906-364-2578
Mailing Address - Fax:
Practice Address - Street 1:209 SILVER ST
Practice Address - Street 2:
Practice Address - City:HURLEY
Practice Address - State:WI
Practice Address - Zip Code:54534-1253
Practice Address - Country:US
Practice Address - Phone:906-285-9710
Practice Address - Fax:855-543-0237
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1860-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional