Provider Demographics
NPI:1013620699
Name:BOLANOS, JUAN JOSE
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:JOSE
Last Name:BOLANOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 CHURCH LN
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-3707
Mailing Address - Country:US
Mailing Address - Phone:516-236-1004
Mailing Address - Fax:510-236-3200
Practice Address - Street 1:12960 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94805-1307
Practice Address - Country:US
Practice Address - Phone:510-215-2280
Practice Address - Fax:510-215-2283
Is Sole Proprietor?:No
Enumeration Date:2022-12-28
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1488401122101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR1488401122OtherCREDENTIALS