Provider Demographics
NPI:1124166632
Name:BOLINO, EDWARD PAUL (PCC)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:PAUL
Last Name:BOLINO
Suffix:
Gender:M
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 BUTLER RD NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-5607
Mailing Address - Country:US
Mailing Address - Phone:330-372-6782
Mailing Address - Fax:
Practice Address - Street 1:318 MAHONING AVE NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-4605
Practice Address - Country:US
Practice Address - Phone:330-395-9563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0000680101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0000001254229OtherANTHEM