Provider Demographics
NPI:1598434896
Name:BOLNER, AMANDA JO
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:BOLNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 WESTERN AVE STE D
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331-1800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2508 WESTERN AVE STE D
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-1800
Practice Address - Country:US
Practice Address - Phone:765-286-5773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)