Provider Demographics
NPI:1245574912
Name:BOLTE PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:BOLTE PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOLTE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:859-426-0200
Mailing Address - Street 1:305 ARTILLERY PARK DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT MITCHELL
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2781
Mailing Address - Country:US
Mailing Address - Phone:859-426-0200
Mailing Address - Fax:859-426-0042
Practice Address - Street 1:305 ARTILLERY PARK DR
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT MITCHELL
Practice Address - State:KY
Practice Address - Zip Code:41017-2781
Practice Address - Country:US
Practice Address - Phone:859-426-0200
Practice Address - Fax:859-426-0042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1298103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1366493298OtherNPI TYPE 1
KY0025693Medicare UPIN