Provider Demographics
NPI:1023200466
Name:BOLEN, SHANNON L (MSW)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:L
Last Name:BOLEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 WEST HILL BLVD
Mailing Address - Street 2:437TH MEDICAL GROUP/SGOH
Mailing Address - City:CHARLESTON AFB
Mailing Address - State:SC
Mailing Address - Zip Code:29404-4704
Mailing Address - Country:US
Mailing Address - Phone:843-963-6972
Mailing Address - Fax:843-963-6930
Practice Address - Street 1:204 WEST HILL BLVD.
Practice Address - Street 2:437TH MEDICAL GROUP/SGOH
Practice Address - City:CHARLESTON AFB
Practice Address - State:SC
Practice Address - Zip Code:29404-4704
Practice Address - Country:US
Practice Address - Phone:843-963-6972
Practice Address - Fax:843-963-6930
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA206421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN