Basic Information
| Provider Information | |||||||||
| NPI: | 1831608694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLIN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ALICE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 501 W SIERRA AVE APT 145 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937041154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599034932 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24511 W JAYNE AVE | ||||||||
| Address2: | |||||||||
| City: | COALINGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932109503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599354300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2017 | ||||||||
| LastUpdateDate: | 09/25/2017 | ||||||||
| 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 | 79414 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 79414 | CA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.