Provider Demographics
NPI:1447691621
Name:BOMLEY, OLISA (LMSW)
Entity type:Individual
Prefix:MRS
First Name:OLISA
Middle Name:
Last Name:BOMLEY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2355
Mailing Address - Country:US
Mailing Address - Phone:208-746-5700
Mailing Address - Fax:208-799-6504
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2431
Practice Address - Country:US
Practice Address - Phone:208-746-5700
Practice Address - Fax:208-799-6504
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW 29090104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker