Healthcare Provider Details

I. General information

NPI: 1710369236
Provider Name (Legal Business Name): JOHN P BOLGER PHD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2015
Last Update Date: 06/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 WILD OLIVE DR
MT PLEASANT SC
29464-7478
US

IV. Provider business mailing address

1305 WILD OLIVE DR
MT PLEASANT SC
29464-7478
US

V. Phone/Fax

Practice location:
  • Phone: 910-987-7285
  • Fax:
Mailing address:
  • Phone: 910-987-7285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number1237
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1237
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number1237
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1237
License Number StateSC

VIII. Authorized Official

Name: JOHN P BOLGER
Title or Position: SOLE OWNER
Credential: PH.D.
Phone: 910-987-7285