MEDICARE: MIA BOLGER MSW, RBT

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
1	106S00000X	Behavior Technician	RBT-17-28232	IL

General Provider Information

NPI Number	:	1245856210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIA BOLGER MSW, RBT

Provider Business Mailing Address
First Line	:	1807 PRAIRIE ST
Second Line	:
City	:	GLENVIEW
State	:	IL
Zip	:	60025-2921
Country	:	US
Telephone Number	:	847-693-1792
Fax Number	:

Provider Business Practice Location Address
First Line	:	3417 N KENNICOTT AVE STE A
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-7824
Country	:	US
Telephone Number	:	224-210-6694
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2020
Last Update Date	:	06/24/2020

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