Healthcare Provider Details

I. General information

NPI: 1891725024
Provider Name (Legal Business Name): JOHN P BOLGER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 04/04/2019
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 Number4800
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4800
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number4800
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number4800
License Number StateOH
# 5
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number4800
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: