Healthcare Provider Details

I. General information

NPI: 1659974814
Provider Name (Legal Business Name): NICOLINA A BOLOGNESE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 N 4TH ST
BROOKLYN NY
11249-3296
US

IV. Provider business mailing address

360 BARLOW AVE APT 23A
STATEN ISLAND NY
10308-1349
US

V. Phone/Fax

Practice location:
  • Phone: 646-450-7748
  • Fax:
Mailing address:
  • Phone: 772-475-0383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number110999
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number098045
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: