Provider Demographics
NPI:1518521962
Name:BOLDT, SAMANTHA LEIGH (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEIGH
Last Name:BOLDT
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 E 50TH ST APT 3G
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-7933
Mailing Address - Country:US
Mailing Address - Phone:914-582-4691
Mailing Address - Fax:
Practice Address - Street 1:360 E 50TH ST APT 3G
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-7933
Practice Address - Country:US
Practice Address - Phone:914-582-4691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023370225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist