Provider Demographics
NPI:1932442837
Name:BOLANOS, NICOLAS ALONZO (MED, EDS)
Entity Type:Individual
Prefix:MR
First Name:NICOLAS
Middle Name:ALONZO
Last Name:BOLANOS
Suffix:
Gender:M
Credentials:MED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 FORD STREET EXTENTION
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916
Mailing Address - Country:US
Mailing Address - Phone:239-461-8388
Mailing Address - Fax:239-790-5121
Practice Address - Street 1:4150 FORD STREET EXTENSION
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916
Practice Address - Country:US
Practice Address - Phone:239-461-8388
Practice Address - Fax:239-790-5121
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH9380101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor