Provider Demographics
NPI:1114041142
Name:BOLOGNA, JOSEPH P (PHD, MFT)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:P
Last Name:BOLOGNA
Suffix:
Gender:M
Credentials:PHD, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11057 BASYE ST
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-1655
Mailing Address - Country:US
Mailing Address - Phone:626-444-0539
Mailing Address - Fax:626-444-7990
Practice Address - Street 1:11057 BASYE ST
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-1655
Practice Address - Country:US
Practice Address - Phone:626-444-0539
Practice Address - Fax:626-444-7990
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 25342106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACSC8984OtherSTAFF CODE