Provider Demographics
NPI:1538393798
Name:BOLAND, KRISTIN M (MA, LPC)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:M
Last Name:BOLAND
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 ROUND LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LUCK
Mailing Address - State:WI
Mailing Address - Zip Code:54853-2017
Mailing Address - Country:US
Mailing Address - Phone:715-472-4166
Mailing Address - Fax:
Practice Address - Street 1:100 POLK COUNTY PLZ
Practice Address - Street 2:SUITE #50
Practice Address - City:BALSAM LAKE
Practice Address - State:WI
Practice Address - Zip Code:54810-9071
Practice Address - Country:US
Practice Address - Phone:715-485-8882
Practice Address - Fax:715-485-8490
Is Sole Proprietor?:No
Enumeration Date:2009-05-04
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4461-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional