Healthcare Provider Details

I. General information

NPI: 1497240030
Provider Name (Legal Business Name): PAIGE BOLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 08/02/2020
Certification Date: 08/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 SHERBURN CT
ORLANDO FL
32828-9017
US

IV. Provider business mailing address

606 SHERBURN CT
ORLANDO FL
32828-9017
US

V. Phone/Fax

Practice location:
  • Phone: 407-883-8636
  • Fax: 407-867-6203
Mailing address:
  • Phone: 407-883-8636
  • Fax: 407-867-6203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ8529
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA17610
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: