Provider Demographics
NPI:1497240030
Name:BOLEN, PAIGE
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:BOLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 SHERBURN CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-9017
Mailing Address - Country:US
Mailing Address - Phone:407-883-8636
Mailing Address - Fax:407-867-6203
Practice Address - Street 1:606 SHERBURN CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-9017
Practice Address - Country:US
Practice Address - Phone:407-883-8636
Practice Address - Fax:407-867-6203
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2020-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ8529235Z00000X
FLSA17610235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty