Provider Demographics
NPI:1851424055
Name:BOLLINGER, EVAN VANDY (MED, LMHC)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:VANDY
Last Name:BOLLINGER
Suffix:
Gender:M
Credentials:MED, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 JUGGLER MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:LEVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:01054-9521
Mailing Address - Country:US
Mailing Address - Phone:413-548-3970
Mailing Address - Fax:
Practice Address - Street 1:53 JUGGLER MEADOW RD
Practice Address - Street 2:
Practice Address - City:LEVERETT
Practice Address - State:MA
Practice Address - Zip Code:01054-9521
Practice Address - Country:US
Practice Address - Phone:413-548-3970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5278101YM0800X
MA2031131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALM1086OtherBCBSMA PROVIDER NUMBER
MA5278OtherLMHC LICENSE NUMBER