Healthcare Provider Details

I. General information

NPI: 1356204358
Provider Name (Legal Business Name): KRISTA JEANETTE BOLOGNA MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 LOWER MAIN ST W
JOHNSON VT
05656-9631
US

IV. Provider business mailing address

6 SUNSET DR
JOHNSON VT
05656-8200
US

V. Phone/Fax

Practice location:
  • Phone: 802-585-4617
  • Fax:
Mailing address:
  • Phone: 802-585-4617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number097.0135395
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: