Provider Demographics
NPI:1841593415
Name:BOLAND, KATHLEEN MICHELLE (DPT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MICHELLE
Last Name:BOLAND
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 AVON ST
Mailing Address - Street 2:UNIT 1
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-1602
Mailing Address - Country:US
Mailing Address - Phone:617-417-8740
Mailing Address - Fax:
Practice Address - Street 1:1493 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1047
Practice Address - Country:US
Practice Address - Phone:617-665-2422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-21
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19318225100000X
MD23376225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist