Provider Demographics
NPI:1346378726
Name:BOLDT, NANCY ANN (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:ANN
Last Name:BOLDT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 LATHAM ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-4635
Mailing Address - Country:US
Mailing Address - Phone:815-967-6886
Mailing Address - Fax:
Practice Address - Street 1:1616 LATHAM ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-4635
Practice Address - Country:US
Practice Address - Phone:815-967-6886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist