Provider Demographics
NPI:1376177071
Name:BOLTER, SHANNON (LADC, IADC, PCDGC)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:BOLTER
Suffix:
Gender:F
Credentials:LADC, IADC, PCDGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 N 49TH ST STE B103
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68132-3172
Mailing Address - Country:US
Mailing Address - Phone:402-200-3808
Mailing Address - Fax:
Practice Address - Street 1:108 N 49TH ST STE B103
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68132-3172
Practice Address - Country:US
Practice Address - Phone:402-200-3808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22R101101YA0400X
NE51101YA0400X
NE1439101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)