Provider Demographics
NPI:1912114042
Name:BOLGER, MARY LYNN (SLP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:LYNN
Last Name:BOLGER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6506 E MOUNTAIN VIEW RD
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-1844
Mailing Address - Country:US
Mailing Address - Phone:480-945-3810
Mailing Address - Fax:
Practice Address - Street 1:1817 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2133
Practice Address - Country:US
Practice Address - Phone:602-523-8988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL5350235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist