MEDICARE: DR. EDWARD P BOLIN PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	P766	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	049886	OTHER	TN	BCBS

General Provider Information

NPI Number	:	1184795775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARD P BOLIN PSY.D.

Provider Business Mailing Address
First Line	:	111 FOREST CT
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37919-5078
Country	:	US
Telephone Number	:	865-588-9919
Fax Number	:	865-909-0422

Provider Business Practice Location Address
First Line	:	111 FOREST CT
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37919-5078
Country	:	US
Telephone Number	:	865-588-9919
Fax Number	:	865-909-0422

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	09/25/2018

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