Provider Demographics
NPI:1225280100
Name:BOLES, LARRY (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:BOLES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 SANDBURG DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-1833
Mailing Address - Country:US
Mailing Address - Phone:916-531-2009
Mailing Address - Fax:916-278-7730
Practice Address - Street 1:46 SANDBURG DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-1833
Practice Address - Country:US
Practice Address - Phone:916-531-2009
Practice Address - Fax:916-278-7730
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP4884235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist