Provider Demographics
NPI:1962512459
Name:BOLAND, DAVID GERARD (MED, LPC)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:GERARD
Last Name:BOLAND
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12750 HEZEL LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6375
Mailing Address - Country:US
Mailing Address - Phone:314-469-3688
Mailing Address - Fax:
Practice Address - Street 1:233 N NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7530
Practice Address - Country:US
Practice Address - Phone:314-567-3500
Practice Address - Fax:314-567-1519
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCS002098101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool