Basic Information
| Provider Information | |||||||||
| NPI: | 1497152110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLDT | ||||||||
| FirstName: | ELISA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.S., BCBA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SOSA | ||||||||
| OtherFirstName: | ELISA | ||||||||
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| OtherCredential: | M.S., BCBA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7567 GREENHAVEN DR APT 390 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958313939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082396540 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7801 FOLSOM BLVD STE 350 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958262624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108324383 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2014 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-14-9854 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.