Provider Demographics
NPI:1710369236
Name:JOHN P BOLGER PHD LLC
Entity Type:Organization
Organization Name:JOHN P BOLGER PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BOLGER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:910-987-7285
Mailing Address - Street 1:1305 WILD OLIVE DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7478
Mailing Address - Country:US
Mailing Address - Phone:910-987-7285
Mailing Address - Fax:
Practice Address - Street 1:1305 WILD OLIVE DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7478
Practice Address - Country:US
Practice Address - Phone:910-987-7285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-20
Last Update Date:2015-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1237103G00000X, 103TA0700X, 103TC0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Multi-Specialty