Provider Demographics
NPI:1669970711
Name:BOLANOS, CECY-LIZETTE
Entity type:Individual
Prefix:
First Name:CECY-LIZETTE
Middle Name:
Last Name:BOLANOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3213 ASTORIA BLVD APT 2R
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-1117
Mailing Address - Country:US
Mailing Address - Phone:269-313-2894
Mailing Address - Fax:
Practice Address - Street 1:307 INTERNATIONAL CIR STE 100
Practice Address - Street 2:
Practice Address - City:HUNT VALLEY
Practice Address - State:MD
Practice Address - Zip Code:21030-1387
Practice Address - Country:US
Practice Address - Phone:410-606-7720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018527-1225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation