Provider Demographics
NPI:1700021235
Name:BOLAND, LAURA (ST)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BOLAND
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2778 BRUCKNER BLVD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10465-1934
Mailing Address - Country:US
Mailing Address - Phone:718-863-4925
Mailing Address - Fax:718-863-5316
Practice Address - Street 1:2778 BRUCKNER BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465-1934
Practice Address - Country:US
Practice Address - Phone:718-863-4925
Practice Address - Fax:718-863-5316
Is Sole Proprietor?:No
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012204-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist