Provider Demographics
NPI:1457610826
Name:BOLANOS, HEATHER M (MS SLP)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:M
Last Name:BOLANOS
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 LINCOLN AVE APT D3
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-5730
Mailing Address - Country:US
Mailing Address - Phone:516-322-6349
Mailing Address - Fax:
Practice Address - Street 1:538 BROADHOLLOW RD STE 202
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3668
Practice Address - Country:US
Practice Address - Phone:516-322-6349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021899235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist