Basic Information
Provider Information | |||||||||
NPI: | 1235260456 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOLIS | ||||||||
FirstName: | RENEE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3176 ABBOTT RD. BLDG. A SUITE 500 | ||||||||
Address2: | ABBOTT CORNERS PROS | ||||||||
City: | ORCHARD PARK | ||||||||
State: | NY | ||||||||
PostalCode: | 14127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7168222117 | ||||||||
FaxNumber: | 7168228165 | ||||||||
Practice Location | |||||||||
Address1: | 3176 ABBOTT RD | ||||||||
Address2: | BUILDING A SUITE 500 | ||||||||
City: | ORCHARD PARK | ||||||||
State: | NY | ||||||||
PostalCode: | 141271069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7168222117 | ||||||||
FaxNumber: | 7168228165 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2007 | ||||||||
LastUpdateDate: | 12/15/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 077991-1 | NY | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.