Provider Demographics
NPI:1316965189
Name:BOLANOS, MARIA LORENA (PT)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:LORENA
Last Name:BOLANOS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:MARIA
Other - Middle Name:LORENA
Other - Last Name:ALBAITERO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:2753 CONEY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-5015
Mailing Address - Country:US
Mailing Address - Phone:718-769-8400
Mailing Address - Fax:718-769-3255
Practice Address - Street 1:2753 CONEY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5015
Practice Address - Country:US
Practice Address - Phone:718-769-8400
Practice Address - Fax:718-769-3255
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026185225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02729591Medicaid
NYQ28L91Medicare ID - Type Unspecified