Provider Demographics
NPI:1508990896
Name:BOLOGNA, DANIEL LOUIS (LCSW)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:LOUIS
Last Name:BOLOGNA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 BREVARD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2149
Mailing Address - Country:US
Mailing Address - Phone:321-632-5792
Mailing Address - Fax:
Practice Address - Street 1:840 BREVARD AVE
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2149
Practice Address - Country:US
Practice Address - Phone:321-632-5792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW0002541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL62-40039OtherUNITED HEALTH CARE
FL275862OtherWELLCARE
FL060332500Medicaid
FLZ3475Medicare ID - Type Unspecified
FL275862OtherWELLCARE
FLZ3475Medicare PIN