Provider Demographics
NPI:1174204499
Name:BOLES, KAYDI JOA (SLP)
Entity type:Individual
Prefix:
First Name:KAYDI
Middle Name:JOA
Last Name:BOLES
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:KAYDI
Other - Middle Name:JOA
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:5426 FM 2021
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-4135
Mailing Address - Country:US
Mailing Address - Phone:936-671-9971
Mailing Address - Fax:
Practice Address - Street 1:5426 FM 2021
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-4135
Practice Address - Country:US
Practice Address - Phone:936-671-9971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117478235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist