Basic Information
| Provider Information | |||||||||
| NPI: | 1922011097 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | AUD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3945 OKEMOS RD | ||||||||
| Address2: | STE B1 | ||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488644207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173490200 | ||||||||
| FaxNumber: | 5173493030 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 N CLIPPERT ST | ||||||||
| Address2: | STE 4 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489124694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173321691 | ||||||||
| FaxNumber: | 5173240210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 05/27/2014 | ||||||||
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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 | 231H00000X | 1601000086 | MI | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 804679861 | 05 | MI | MEDICAID | 540C312880 | 01 | MI | BCBS HEARING AIDS | OTHER | 640C326130 | 01 | MI | BCBS SERVICES | OTHER |