Basic Information
| Provider Information | |||||||||
| NPI: | 1740933910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLTHOUSE | ||||||||
| FirstName: | GARRET | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | MA, MCFC, LAC, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 91638 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857521638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202753506 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3295 W INA RD STE 125 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857412195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202571168 | ||||||||
| FaxNumber: | 5203064861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2022 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | LAC-21055 | AZ | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.