Provider Demographics
NPI:1750481446
Name:BOLEN, BARBARA BRADLEY (PHD)
Entity Type:Individual
Prefix:DR
First Name:BARBARA
Middle Name:BRADLEY
Last Name:BOLEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 SCUDDER AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3020
Mailing Address - Country:US
Mailing Address - Phone:516-454-6921
Mailing Address - Fax:
Practice Address - Street 1:17 CONKLIN ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-2557
Practice Address - Country:US
Practice Address - Phone:516-454-6921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009514-0103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01249889Medicaid
NYV65731Medicare ID - Type Unspecified