Provider Demographics
NPI:1457563470
Name:BOLANOS, JOSE LUIS
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:LUIS
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 1:2116 N FREDERIC ST
Mailing Address - Street 2:18646 OXNARD ST
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-3323
Mailing Address - Country:US
Mailing Address - Phone:818-953-8926
Mailing Address - Fax:
Practice Address - Street 1:2116 N FREDERIC ST
Practice Address - Street 2:18646 OXNARD ST
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91504-3323
Practice Address - Country:US
Practice Address - Phone:818-953-8926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)