Basic Information
| Provider Information | |||||||||
| NPI: | 1174133250 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLAND | ||||||||
| FirstName: | ANNEMARIE | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | SPEECH/LANGUAGE PATH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7455 BUFFALO AVE | ||||||||
| Address2: | |||||||||
| City: | NIAGARA FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 143044105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165344984 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 630 66TH ST | ||||||||
| Address2: | |||||||||
| City: | NIAGARA FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 143042212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162864211 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2020 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 029948 | NY | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.