1316404544 NPI number — BOLD RULER, LLC

Table of content: (NPI 1316404544)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316404544 NPI number — BOLD RULER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOLD RULER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SUMMIT COUNSELING SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316404544
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 BURLEIGH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23505-3413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-472-1379
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
821 W 21ST ST STE 209
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23517-1500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-280-1777
Provider Business Practice Location Address Fax Number:
757-585-3521
Provider Enumeration Date:
02/24/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MALONEY
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
OWNER/CLINICIAN
Authorized Official Telephone Number:
757-472-1379

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010001625 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0701003466 . This is a "LPC" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0717001169 . This is a "LMFT" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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