Provider Demographics
NPI:1427149954
Name:BOLIN, ROBERT WAYNE (CCDC1)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WAYNE
Last Name:BOLIN
Suffix:
Gender:M
Credentials:CCDC1
Other - Prefix:MR
Other - First Name:ROBERT
Other - Middle Name:WAYNE
Other - Last Name:BOLIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CCDC1
Mailing Address - Street 1:543 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43203-1278
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:543 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43203-1278
Practice Address - Country:US
Practice Address - Phone:614-257-5338
Practice Address - Fax:614-257-5418
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH970107101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)