Provider Demographics
NPI:1770509556
Name:BOLKOVATZ, MARY ANN (CNS)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:BOLKOVATZ
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 29TH ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2358
Mailing Address - Country:US
Mailing Address - Phone:303-261-5037
Mailing Address - Fax:
Practice Address - Street 1:777 29TH ST
Practice Address - Street 2:SUITE 401
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2358
Practice Address - Country:US
Practice Address - Phone:303-261-5037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO67698364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
COD11515Medicare ID - Type Unspecified
COP22276Medicare UPIN