1477524254 NPI number — MARY BOBOLA LICSW

Table of content: MARY BOBOLA LICSW (NPI 1477524254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477524254 NPI number — MARY BOBOLA LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOBOLA
Provider First Name:
MARY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477524254
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 PLANTATION ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-368-7888
Provider Business Mailing Address Fax Number:
508-792-4392

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
191 MAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-368-7888
Provider Business Practice Location Address Fax Number:
508-792-4392
Provider Enumeration Date:
01/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  1026597 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1061933 . This is a "CIGNA HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 33824 . This is a "FALLON COMMUNITY HEALTH P" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2043637 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "PRIVATE HEALTHCARE SYSTEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 580244000 . This is a "MAGELLAN BEHAVIORAL HEALT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 800011108 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P07209 . This is a "BLUE SHIELD HMO BLUE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "PACIFICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "THREE RIVERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 785946 . This is a "MVP HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P20253 . This is a "MEDICARE B" identifier . This identifiers is of the category "OTHER".
  • Identifier: P07209 . This is a "BLUE SHIELD INDEMNITY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "HEALTHCARE VALUE MANAGEME" identifier . This identifiers is of the category "OTHER".
  • Identifier: P07209 . This is a "BLUE CARE ELECT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 04247226 . This is a "ONE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266006 . This is a "TRICARE CHAMPUS" identifier . This identifiers is of the category "OTHER".




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