Provider Demographics
NPI:1063865582
Name:BOLAN, EMILY (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:BOLAN
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4209 23RD AVE APT 2F
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-1530
Mailing Address - Country:US
Mailing Address - Phone:518-915-5105
Mailing Address - Fax:
Practice Address - Street 1:1111 44TH RD STE 402
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-5115
Practice Address - Country:US
Practice Address - Phone:518-915-5105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020676225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist