Provider Demographics
NPI:1275841140
Name:BOLANOS ANDRADE, ALICIA HELENA (SLPD,CCC-SLP/TSHH/BE)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:HELENA
Last Name:BOLANOS ANDRADE
Suffix:
Gender:F
Credentials:SLPD,CCC-SLP/TSHH/BE
Other - Prefix:DR
Other - First Name:ALICIA
Other - Middle Name:HELENA
Other - Last Name:BOLANOS ANDRADE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SLPD,CCC-SLP/TSHH/BE
Mailing Address - Street 1:628 TINTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455
Mailing Address - Country:US
Mailing Address - Phone:718-292-5478
Mailing Address - Fax:201-944-4493
Practice Address - Street 1:628 TINTON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-3218
Practice Address - Country:US
Practice Address - Phone:718-292-5478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2023-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022627-1235Z00000X, 235Z00000X, 235Z00000X
NJ41YS00754300235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03671116Medicaid