Provider Demographics
NPI:1285946095
Name:BOULLOSA, ALICE MENDEZ (MSW, LMFT)
Entity type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:MENDEZ
Last Name:BOULLOSA
Suffix:
Gender:F
Credentials:MSW, LMFT
Other - Prefix:MS
Other - First Name:ALICE
Other - Middle Name:NORMA
Other - Last Name:MENDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:200 S HOOVER BLVD
Mailing Address - Street 2:BLDG 200 SUITE 100
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-3540
Mailing Address - Country:US
Mailing Address - Phone:813-789-6070
Mailing Address - Fax:
Practice Address - Street 1:200 S HOOVER BLVD
Practice Address - Street 2:BLDG 200 SUITE 100
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3540
Practice Address - Country:US
Practice Address - Phone:813-789-6070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT0001228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist