Provider Demographics
NPI:1548775141
Name:BOLANOS, GRETHEL VIRGINIA
Entity Type:Individual
Prefix:
First Name:GRETHEL
Middle Name:VIRGINIA
Last Name:BOLANOS
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 1:1740 SW 87TH TER
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-2025
Mailing Address - Country:US
Mailing Address - Phone:305-469-9730
Mailing Address - Fax:
Practice Address - Street 1:10200 NW 25TH ST STE 211
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-5927
Practice Address - Country:US
Practice Address - Phone:786-317-4478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-74134106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician