Provider Demographics
NPI:1750580049
Name:BOLANO, MICHELLE (DPT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BOLANO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 SHERIDAN RD
Mailing Address - Street 2:APT 2B
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3119
Mailing Address - Country:US
Mailing Address - Phone:847-204-7919
Mailing Address - Fax:
Practice Address - Street 1:1800 HOLLISTER DR
Practice Address - Street 2:SUITE 205
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5263
Practice Address - Country:US
Practice Address - Phone:847-918-7947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program