Provider Demographics
NPI:1124572458
Name:BOLANDER, BRIE
Entity type:Individual
Prefix:
First Name:BRIE
Middle Name:
Last Name:BOLANDER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:BRIE
Other - Middle Name:
Other - Last Name:BOWIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:440 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27292-2634
Mailing Address - Country:US
Mailing Address - Phone:336-236-6546
Mailing Address - Fax:336-236-9546
Practice Address - Street 1:440 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-2634
Practice Address - Country:US
Practice Address - Phone:336-236-6546
Practice Address - Fax:336-236-9546
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4147-154235Z00000X
NC30003569235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1548242829Medicaid
WI52-6552OtherMEDICARE#