Provider Demographics
NPI:1164072872
Name:BOLEY, MARY KAITLYN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAITLYN
Last Name:BOLEY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KAITLYN
Other - Last Name:GERBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2121 SWEET GUM DR
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:TX
Mailing Address - Zip Code:75409-0117
Mailing Address - Country:US
Mailing Address - Phone:214-837-3608
Mailing Address - Fax:
Practice Address - Street 1:2121 SWEET GUM DR
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:TX
Practice Address - Zip Code:75409-0117
Practice Address - Country:US
Practice Address - Phone:214-837-3608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-14
Last Update Date:2019-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110916235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist