Provider Demographics
NPI:1265957872
Name:BOLAN, ALEXANDRA MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:MARIE
Last Name:BOLAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:MARIE
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:70 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-2523
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:195 DANBURY RD STE B210
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-6013
Practice Address - Country:US
Practice Address - Phone:203-913-4713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0093761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical