Provider Demographics
NPI:1932214541
Name:BOLICK, LATINA (LPC, NCC)
Entity type:Individual
Prefix:MS
First Name:LATINA
Middle Name:
Last Name:BOLICK
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6713 WESTOVER DR
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76049-4163
Mailing Address - Country:US
Mailing Address - Phone:254-760-5542
Mailing Address - Fax:
Practice Address - Street 1:6713 WESTOVER DR
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-4163
Practice Address - Country:US
Practice Address - Phone:254-760-5542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18757101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1719098Medicaid