Provider Demographics
NPI:1790901874
Name:BOLIVAR, LUIS FERNANDO (LIC MFT)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:FERNANDO
Last Name:BOLIVAR
Suffix:
Gender:M
Credentials:LIC MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10329 HOLE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-1747
Mailing Address - Country:US
Mailing Address - Phone:951-351-1600
Mailing Address - Fax:951-351-9400
Practice Address - Street 1:10329 HOLE AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-1747
Practice Address - Country:US
Practice Address - Phone:951-351-1600
Practice Address - Fax:951-351-9400
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 21014106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist