Provider Demographics
NPI:1639304934
Name:BOLIVAR, MARIO JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:
Last Name:BOLIVAR
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:MARIO
Other - Middle Name:
Other - Last Name:BOLIVAR
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:112 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-7370
Mailing Address - Country:US
Mailing Address - Phone:678-237-1269
Mailing Address - Fax:
Practice Address - Street 1:112 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-7370
Practice Address - Country:US
Practice Address - Phone:678-237-1269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-15
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12141041C0700X
FL30711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical