Provider Demographics
NPI:1114747268
Name:BOLANOS, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BOLANOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5780 AUTUMN OAKS LN
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-1124
Mailing Address - Country:US
Mailing Address - Phone:239-961-2571
Mailing Address - Fax:
Practice Address - Street 1:8803 TAMIAMI TRL E
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34113-3347
Practice Address - Country:US
Practice Address - Phone:239-272-0838
Practice Address - Fax:239-310-2045
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-383448106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician