Provider Demographics
NPI:1568724201
Name:BOLINA, NICOLE L (LMSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:BOLINA
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 1:1380 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2098
Mailing Address - Country:US
Mailing Address - Phone:631-369-0022
Mailing Address - Fax:
Practice Address - Street 1:1380 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2098
Practice Address - Country:US
Practice Address - Phone:631-369-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086400-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker