Basic Information
| Provider Information | |||||||||
| NPI: | 1053926626 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLANO | ||||||||
| FirstName: | CARL ANN REI | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | ACSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 S LA FAYETTE PARK PL FL 3 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900571607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2132522100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 520 S LA FAYETTE PARK PL FL 3 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900571607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2132522100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2020 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 390200000X | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | ACSW104971 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.