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NPI Code Detail

MEDICARE: MS. SUSAN LYNN BOLOGNA

MEDICARE: MS. SUSAN LYNN BOLOGNA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor23440MI

General Provider Information

NPI Number : 1164681268
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. SUSAN LYNN BOLOGNA
Provider Business Mailing Address
First Line : 30233 BARBARY CT
Second Line :
City : WARREN
State : MI
Zip : 48093-3073
Country : US
Telephone Number : 586-573-4715
Fax Number :
Provider Business Practice Location Address
First Line : 35514 INDIGO DR
Second Line :
City : STERLING HEIGHTS
State : MI
Zip : 48310-4946
Country : US
Telephone Number : 586-212-2671
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/03/2008
Last Update Date : 06/03/2008

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