Basic Information
Provider Information | |||||||||
NPI: | 1508292426 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOLDT | ||||||||
FirstName: | BROOKE | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S. CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GRUNERT | ||||||||
OtherFirstName: | BROOKE | ||||||||
OtherMiddleName: | A. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.S. CCC-SLP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6859 SHADY AVE | ||||||||
Address2: |   | ||||||||
City: | CROGHAN | ||||||||
State: | NY | ||||||||
PostalCode: | 133272241 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3152866465 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 25059 WOOLWORTH ST | ||||||||
Address2: |   | ||||||||
City: | CARTHAGE | ||||||||
State: | NY | ||||||||
PostalCode: | 13619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154935000 | ||||||||
FaxNumber: | 3154937036 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/24/2013 | ||||||||
LastUpdateDate: | 09/18/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 023901 | NY | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.