Healthcare Provider Details

I. General information

NPI: 1396075099
Provider Name (Legal Business Name): SUSAN T BOLAND P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2010
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N JACKSON ST LOWR FLOOR
MEDIA PA
19063-2926
US

IV. Provider business mailing address

313 DARTMOUTH AVE APT. C
SWARTHMORE PA
19081-1546
US

V. Phone/Fax

Practice location:
  • Phone: 610-499-8966
  • Fax:
Mailing address:
  • Phone: 610-499-8966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT002023E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: