Provider Demographics
NPI:1326149725
Name:BOLSTER, LARRY P (LCSW)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:P
Last Name:BOLSTER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-945-5247
Mailing Address - Fax:207-947-0435
Practice Address - Street 1:86 DAVIS RD
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-992-2205
Practice Address - Fax:207-992-2207
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC99631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432426799Medicaid
Q52700Medicare ID - Type Unspecified
ME432426799Medicaid