Provider Demographics
NPI:1508054529
Name:BOLL, SUSAN ELLEN (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ELLEN
Last Name:BOLL
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-1787
Mailing Address - Country:US
Mailing Address - Phone:419-520-2386
Mailing Address - Fax:
Practice Address - Street 1:2011 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-1787
Practice Address - Country:US
Practice Address - Phone:419-520-2386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-3932235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist