Provider Demographics
NPI:1558045195
Name:BOLANOS, AXEL (LPC-A)
Entity Type:Individual
Prefix:
First Name:AXEL
Middle Name:
Last Name:BOLANOS
Suffix:
Gender:M
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 ANAYA ST
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-9723
Mailing Address - Country:US
Mailing Address - Phone:956-422-5855
Mailing Address - Fax:
Practice Address - Street 1:807 QUINCE AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-2445
Practice Address - Country:US
Practice Address - Phone:956-800-5679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19818101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor