Provider Demographics
NPI:1063908028
Name:BOLICK, JOHANNA (COTA)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:BOLICK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 CEDAR HILL DR
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-3044
Mailing Address - Country:US
Mailing Address - Phone:973-934-7399
Mailing Address - Fax:
Practice Address - Street 1:19 CEDAR HILL DR
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:NY
Practice Address - Zip Code:10990-3044
Practice Address - Country:US
Practice Address - Phone:973-934-7399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009759-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant