Provider Demographics
NPI:1649829615
Name:BOLAND, BRIDGID M
Entity type:Individual
Prefix:
First Name:BRIDGID
Middle Name:M
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 1:188 PINE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-2520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1225 BAY RIDGE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-6015
Practice Address - Country:US
Practice Address - Phone:516-375-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1230726181235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist