Provider Demographics
NPI:1568942407
Name:BOLIVAR, CARMEN LIDIA
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:LIDIA
Last Name:BOLIVAR
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 1:9206 HOLLOW BEND DR
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-5095
Mailing Address - Country:US
Mailing Address - Phone:305-707-8615
Mailing Address - Fax:
Practice Address - Street 1:9206 HOLLOW BEND DR
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5095
Practice Address - Country:US
Practice Address - Phone:305-707-8615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13466101YM0800X
TX88155101YM0800X
CA15890101YM0800X
GALPC009873101YP2500X
NC16651101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional