Provider Demographics
NPI:1679095269
Name:BOLAND, MELINDA
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:
Last Name:BOLAND
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 1:4455 NE HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-9695
Mailing Address - Country:US
Mailing Address - Phone:541-750-1132
Mailing Address - Fax:
Practice Address - Street 1:228 5TH AVE SW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-0052
Practice Address - Country:US
Practice Address - Phone:541-926-2203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL113221041C0700X
OR106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical