Provider Demographics
NPI:1205447000
Name:MONCADA BOLANOS, GEORJANA E (MS)
Entity type:Individual
Prefix:
First Name:GEORJANA
Middle Name:E
Last Name:MONCADA BOLANOS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 W RAMSEY ST
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-4477
Mailing Address - Country:US
Mailing Address - Phone:951-849-7142
Mailing Address - Fax:
Practice Address - Street 1:1330 W RAMSEY ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-4477
Practice Address - Country:US
Practice Address - Phone:951-849-7142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA390200000X
CA154442106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program