Provider Demographics
NPI:1689259624
Name:BOLAN, MEREDITH
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:BOLAN
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 1:920 N. SPRING
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 N. SPRING
Practice Address - Street 2:
Practice Address - City:LAGRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526
Practice Address - Country:US
Practice Address - Phone:708-528-5374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical