Provider Demographics
NPI:1174255350
Name:BOLANOS, LAUREN ALEXANDRA (BCBA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ALEXANDRA
Last Name:BOLANOS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10223 MCINTYRE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28134-7006
Mailing Address - Country:US
Mailing Address - Phone:704-520-0955
Mailing Address - Fax:
Practice Address - Street 1:10223 MCINTYRE RIDGE RD
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28134-7006
Practice Address - Country:US
Practice Address - Phone:704-520-0955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-27
Last Update Date:2025-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1-25-84732103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst