Healthcare Provider Details

I. General information

NPI: 1124166632
Provider Name (Legal Business Name): EDWARD PAUL BOLINO PCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 MAHONING AVE NW
WARREN OH
44483-4605
US

IV. Provider business mailing address

501 BUTLER RD NE
WARREN OH
44483-5607
US

V. Phone/Fax

Practice location:
  • Phone: 330-395-9563
  • Fax:
Mailing address:
  • Phone: 330-372-6782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE0000680
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: