Provider Demographics
NPI:1659974814
Name:BOLOGNESE, NICOLINA A
Entity Type:Individual
Prefix:
First Name:NICOLINA
Middle Name:A
Last Name:BOLOGNESE
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 1:360 BARLOW AVE APT 23A
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-1349
Mailing Address - Country:US
Mailing Address - Phone:772-475-0383
Mailing Address - Fax:
Practice Address - Street 1:134 N 4TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-3296
Practice Address - Country:US
Practice Address - Phone:646-450-7748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY110999104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker