Provider Demographics
NPI:1194446435
Name:BOLANOS, DAVID ANTONY (LMHC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ANTONY
Last Name:BOLANOS
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 WEATHERED WOOD CIR
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-4207
Mailing Address - Country:US
Mailing Address - Phone:321-285-6605
Mailing Address - Fax:
Practice Address - Street 1:1017 WEATHERED WOOD CIR
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-4207
Practice Address - Country:US
Practice Address - Phone:321-285-6605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21174101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional