Provider Demographics
NPI:1508292426
Name:BOLDT, BROOKE A (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:A
Last Name:BOLDT
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:A
Other - Last Name:GRUNERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:6859 SHADY AVE
Mailing Address - Street 2:
Mailing Address - City:CROGHAN
Mailing Address - State:NY
Mailing Address - Zip Code:13327-2241
Mailing Address - Country:US
Mailing Address - Phone:315-286-6465
Mailing Address - Fax:
Practice Address - Street 1:25059 WOOLWORTH ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619
Practice Address - Country:US
Practice Address - Phone:315-493-5000
Practice Address - Fax:315-493-7036
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023901235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist