MEDICARE: KAYLEE MAUDE BOLAR MSW, LSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker

General Provider Information

NPI Number	:	1255154019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLEE MAUDE BOLAR MSW, LSW

Provider Business Mailing Address
First Line	:	2008 CUMBERLAND ST
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61103-4766
Country	:	US
Telephone Number	:	773-733-3016
Fax Number	:

Provider Business Practice Location Address
First Line	:	555 S PERRYVILLE RD STE 222
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2527
Country	:	US
Telephone Number	:	815-331-1023
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2024
Last Update Date	:	11/08/2024

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