Provider Demographics
NPI:1982398509
Name:BOLO, BREANNA LYNN (L-LMSW)
Entity Type:Individual
Prefix:MRS
First Name:BREANNA
Middle Name:LYNN
Last Name:BOLO
Suffix:
Gender:F
Credentials:L-LMSW
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:LYNN
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:L-LMSW
Mailing Address - Street 1:2353 BADGER STREET
Mailing Address - Street 2:2353 BADGER STREET
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2303
Mailing Address - Country:US
Mailing Address - Phone:906-273-1121
Mailing Address - Fax:906-225-6706
Practice Address - Street 1:2353 BADGER STREET. -FUNCTIONAL BEHAVIOR SERVICE
Practice Address - Street 2:2353 BADGER STREET
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2303
Practice Address - Country:US
Practice Address - Phone:906-273-1121
Practice Address - Fax:906-225-6706
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851116557104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker