Provider Demographics
NPI:1003318338
Name:BOLDT, MIKAILA E (DPT)
Entity Type:Individual
Prefix:
First Name:MIKAILA
Middle Name:E
Last Name:BOLDT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 SE TACOMA ST UNIT 122
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6639
Mailing Address - Country:US
Mailing Address - Phone:971-361-9442
Mailing Address - Fax:888-645-6068
Practice Address - Street 1:580 S PAGE ST
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-5837
Practice Address - Country:US
Practice Address - Phone:717-673-2476
Practice Address - Fax:888-645-6068
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP22022225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist