Provider Demographics
NPI:1578797742
Name:BOLT, KATHLEEN A (LSCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:A
Last Name:BOLT
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:MS
Other - First Name:KATIE
Other - Middle Name:A
Other - Last Name:BOLT-GOEKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LSCSW
Mailing Address - Street 1:9218 METCALF AVE
Mailing Address - Street 2:A333
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-1476
Mailing Address - Country:US
Mailing Address - Phone:785-393-0215
Mailing Address - Fax:
Practice Address - Street 1:9319 DEARBORN ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66207-2421
Practice Address - Country:US
Practice Address - Phone:785-393-0215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLSCSW10481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical