Provider Demographics
NPI:1578091583
Name:SAMUEL T BOLIN JR LCSW-C, LLC
Entity Type:Organization
Organization Name:SAMUEL T BOLIN JR LCSW-C, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:BOLIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:443-310-0466
Mailing Address - Street 1:1013 BLUEBELLS RD
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-2059
Mailing Address - Country:US
Mailing Address - Phone:443-310-0466
Mailing Address - Fax:443-231-4331
Practice Address - Street 1:939 ELKRIDGE LANDING RD STE 350
Practice Address - Street 2:
Practice Address - City:LINTHICUM
Practice Address - State:MD
Practice Address - Zip Code:21090-2909
Practice Address - Country:US
Practice Address - Phone:443-588-8753
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-03
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD206971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty