Provider Demographics
NPI:1750608337
Name:BOMAR, MICHAEL ANTHONY II (MSW, LCSW, LISW-CP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:BOMAR
Suffix:II
Gender:M
Credentials:MSW, LCSW, LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 J N PEASE PL STE 103
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4560
Mailing Address - Country:US
Mailing Address - Phone:803-984-7051
Mailing Address - Fax:
Practice Address - Street 1:1909 J N PEASE PL STE 103
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4560
Practice Address - Country:US
Practice Address - Phone:803-984-7051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-22
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0080051041C0700X
SC102671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical