Basic Information
| Provider Information | |||||||||
| NPI: | 1649945114 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLDT | ||||||||
| FirstName: | LEA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193564658 | ||||||||
| FaxNumber: | 3193562587 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193564658 | ||||||||
| FaxNumber: | 3193562587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2021 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | 109669 | IA | N | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | 109669 | IA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | 109669 | IA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TF0000X | 109669 | IA | N | Behavioral Health & Social Service Providers | Psychologist | Family | 103TM1800X | 109669 | IA | N | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities | 103TP2701X | 109669 | IA | N | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 103T00000X | 109669 | IA | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.