Provider Demographics
NPI:1588154827
Name:BOLEN, BRIDGETTE (BCBA 1-18-33746)
Entity type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:
Last Name:BOLEN
Suffix:
Gender:F
Credentials:BCBA 1-18-33746
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E. 22ND ST.
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-1394
Mailing Address - Country:US
Mailing Address - Phone:630-919-8218
Mailing Address - Fax:
Practice Address - Street 1:400 E. 22ND ST. SUITE A
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-1394
Practice Address - Country:US
Practice Address - Phone:630-919-8218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-18-33746103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst