Provider Demographics
NPI:1366493298
Name:BOLTE, LAURA ROSE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ROSE
Last Name:BOLTE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 ARTILLERY PARK DR UNIT 102
Mailing Address - Street 2:
Mailing Address - City:FORT MITCHELL
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2794
Mailing Address - Country:US
Mailing Address - Phone:859-426-0200
Mailing Address - Fax:859-426-0042
Practice Address - Street 1:305 ARTILLERY PARK DR UNIT 102
Practice Address - Street 2:
Practice Address - City:FORT MITCHELL
Practice Address - State:KY
Practice Address - Zip Code:41017-2794
Practice Address - Country:US
Practice Address - Phone:859-426-0200
Practice Address - Fax:859-426-0042
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY129227103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0146114Medicaid
KY7100301780Medicaid
KY7100301780Medicaid
KYK188810Medicare PIN