Provider Demographics
NPI:1699755132
Name:BOLOGNA, MELINA A (MA)
Entity type:Individual
Prefix:MRS
First Name:MELINA
Middle Name:A
Last Name:BOLOGNA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3805 CHRISTIE LN
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-4054
Mailing Address - Country:US
Mailing Address - Phone:586-323-8292
Mailing Address - Fax:
Practice Address - Street 1:11111 HALL RD
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48317-5716
Practice Address - Country:US
Practice Address - Phone:586-292-7260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006188101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional