Provider Demographics
NPI:1578619755
Name:BOLTER, KATHLEEN (KAY) (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN (KAY)
Middle Name:
Last Name:BOLTER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 VETERANS BLVD
Mailing Address - Street 2:STE 210
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-1419
Mailing Address - Country:US
Mailing Address - Phone:650-591-1366
Mailing Address - Fax:650-306-9323
Practice Address - Street 1:1355 SAN CARLOS AVE STE B
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-5603
Practice Address - Country:US
Practice Address - Phone:650-591-1366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10555103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL105550Medicare ID - Type Unspecified