Provider Demographics
NPI:1487840609
Name:BOULT, RENEE J
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:J
Last Name:BOULT
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 1:2500 BISSELL AVE
Mailing Address - Street 2:2500 BISSELL
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-1815
Mailing Address - Country:US
Mailing Address - Phone:510-231-3961
Mailing Address - Fax:
Practice Address - Street 1:2500 BISSELL AVE
Practice Address - Street 2:2500 BISSELL AVE
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-1815
Practice Address - Country:US
Practice Address - Phone:510-231-3961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator