Provider Demographics
NPI:1275841165
Name:BOULUKOS, KAITLYN ELIZABETH (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KAITLYN
Middle Name:ELIZABETH
Last Name:BOULUKOS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3 MILLER AVENUE
Mailing Address - Street 2:
Mailing Address - City:SHOREHAM
Mailing Address - State:NY
Mailing Address - Zip Code:11786
Mailing Address - Country:US
Mailing Address - Phone:631-821-8231
Mailing Address - Fax:631-821-8249
Practice Address - Street 1:3 MILLER AVENUE
Practice Address - Street 2:
Practice Address - City:SHOREHAM
Practice Address - State:NY
Practice Address - Zip Code:11786
Practice Address - Country:US
Practice Address - Phone:631-821-8231
Practice Address - Fax:631-821-8249
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1170343235Z00000X
NY021000-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist