Provider Demographics
NPI:1528416682
Name:BOLITHO, WESLEY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:BOLITHO
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 NW CORNELL AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1150
Mailing Address - Country:US
Mailing Address - Phone:321-480-9049
Mailing Address - Fax:
Practice Address - Street 1:322 NW CORNELL AVE
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-1150
Practice Address - Country:US
Practice Address - Phone:321-480-9049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SA15293235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist