1881999647 NPI number — TERESA Y BOLT LPCC-S

Table of content: TERESA Y BOLT LPCC-S (NPI 1881999647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881999647 NPI number — TERESA Y BOLT LPCC-S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLT
Provider First Name:
TERESA
Provider Middle Name:
Y
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPCC-S
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRAY
Provider Other First Name:
TERESA
Provider Other Middle Name:
Y
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPCC-S
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881999647
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 SUNBURY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHILLICOTHEE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45601-3062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-637-9768
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5982 RHODES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENT
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44240-8100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-676-8000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/25/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  E.0900362SUPV , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0301050 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".