Basic Information
| Provider Information | |||||||||
| NPI: | 1871840009 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLANOS | ||||||||
| FirstName: | LIZA | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2351 CARDINAL LANE | ||||||||
| Address2: | ANNEX B | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585732227 | ||||||||
| FaxNumber: | 8584962113 | ||||||||
| Practice Location | |||||||||
| Address1: | 1051 PICADOR BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921543548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196283665 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2012 | ||||||||
| LastUpdateDate: | 01/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | LMFT94583 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.