Provider Demographics
NPI:1548240500
Name:BOLTZ, ROBERTA (PT)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:BOLTZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070
Mailing Address - Country:US
Mailing Address - Phone:307-745-8851
Mailing Address - Fax:307-742-0961
Practice Address - Street 1:1909 VISTA DR
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070
Practice Address - Country:US
Practice Address - Phone:307-745-8851
Practice Address - Fax:307-742-0961
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT199225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY650024124OtherRAILROAD MEDICARE
310762OtherBCBS
WY104232700Medicaid
310762OtherBCBS