Healthcare Provider Details

I. General information

NPI: 1750128906
Provider Name (Legal Business Name): CORIEN BOLOGNA LCAT, ATR-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 08/03/2024
Certification Date: 08/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MAIN ST
PORT JEFFERSON NY
11777-2250
US

IV. Provider business mailing address

15 PARKRIDGE CIR
PORT JEFFERSON STATION NY
11776-3418
US

V. Phone/Fax

Practice location:
  • Phone: 631-682-9507
  • Fax:
Mailing address:
  • Phone: 631-682-9507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number2936702
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number001744-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: