Provider Demographics
NPI:1376663161
Name:BOLTWOOD, KAREN A
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:A
Last Name:BOLTWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 COBBLESTONE CIR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4501
Mailing Address - Country:US
Mailing Address - Phone:209-572-0511
Mailing Address - Fax:209-526-0908
Practice Address - Street 1:2020 COFFEE RD STE A5
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2407
Practice Address - Country:US
Practice Address - Phone:209-248-5505
Practice Address - Fax:855-821-1966
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53088106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist