Provider Demographics
NPI:1417657792
Name:BOLZAN, LUCIE
Entity Type:Individual
Prefix:
First Name:LUCIE
Middle Name:
Last Name:BOLZAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 N ARDMORE AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3233
Mailing Address - Country:US
Mailing Address - Phone:914-319-6616
Mailing Address - Fax:
Practice Address - Street 1:1080 S LA CIENEGA BLVD STE 208
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-2680
Practice Address - Country:US
Practice Address - Phone:323-426-6402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician