Provider Demographics
NPI:1831466531
Name:BOLGER, TINA MARIE (MA, CCC - SLP)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:BOLGER
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 1:10 KIMBERLY CT
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-4600
Mailing Address - Country:US
Mailing Address - Phone:718-981-8800
Mailing Address - Fax:718-815-4677
Practice Address - Street 1:11 CLOVE LAKE PL
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-2712
Practice Address - Country:US
Practice Address - Phone:718-981-8800
Practice Address - Fax:718-815-4677
Is Sole Proprietor?:No
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012388235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist