Healthcare Provider Details

I. General information

NPI: 1730979907
Provider Name (Legal Business Name): MRS. STEPHANIE M BOLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2025
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 S N ST
LOMPOC CA
93436-6606
US

IV. Provider business mailing address

2233 CORDOBAN LN
SANTA MARIA CA
93455-1379
US

V. Phone/Fax

Practice location:
  • Phone: 805-742-3300
  • Fax:
Mailing address:
  • Phone: 559-589-4003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number240057453
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: