Provider Demographics
NPI:1992335202
Name:BOLAND, CAITLIN CARROLL (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:CARROLL
Last Name:BOLAND
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 MORRIS RD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:FL
Mailing Address - Zip Code:32344-3105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:375 MORRIS RD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:FL
Practice Address - Zip Code:32344-3105
Practice Address - Country:US
Practice Address - Phone:954-261-2059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-26
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA15173235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist