Healthcare Provider Details

I. General information

NPI: 1083437479
Provider Name (Legal Business Name): MICHAEL A BOLEN NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 NJ-35
CLIFFWOOD NJ
07721
US

IV. Provider business mailing address

7 RIVERSIDE DR
CLARK NJ
07066-1524
US

V. Phone/Fax

Practice location:
  • Phone: 732-812-5489
  • Fax:
Mailing address:
  • Phone: 908-380-6307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: