Provider Demographics
NPI:1861446007
Name:BOLDT, RANDAL W (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:W
Last Name:BOLDT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3708 W WACO DR
Mailing Address - Street 2:STE. 3
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-5381
Mailing Address - Country:US
Mailing Address - Phone:254-717-7427
Mailing Address - Fax:254-755-8050
Practice Address - Street 1:3708 W WACO DR
Practice Address - Street 2:STE. 3
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5381
Practice Address - Country:US
Practice Address - Phone:254-717-7427
Practice Address - Fax:254-755-8050
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31358103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0048HCOtherBLUE CROSS BLUE SHIELD
TX00438PMedicare ID - Type Unspecified