Healthcare Provider Details

I. General information

NPI: 1568932580
Provider Name (Legal Business Name): ATHENA BOLINGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 MAIN ST
WILLIMANTIC CT
06226-1910
US

IV. Provider business mailing address

20 GERALDINE DR
ELLINGTON CT
06029-2407
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9431
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: