Provider Demographics
NPI:1851535934
Name:BOISSELLE, DOLORES R (AUD)
Entity Type:Individual
Prefix:MRS
First Name:DOLORES
Middle Name:R
Last Name:BOISSELLE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE BROADWAY
Mailing Address - Street 2:SUITE 302
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07407
Mailing Address - Country:US
Mailing Address - Phone:201-773-8962
Mailing Address - Fax:201-773-8963
Practice Address - Street 1:ONE BROADWAY
Practice Address - Street 2:SUITE 302
Practice Address - City:ELMWOOD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07407
Practice Address - Country:US
Practice Address - Phone:201-773-8962
Practice Address - Fax:201-773-8963
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YA00011400231H00000X
41YA00011400231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0974382Medicaid