Provider Demographics
NPI:1902194442
Name:BOLDMAN, LARIN B
Entity Type:Individual
Prefix:
First Name:LARIN
Middle Name:B
Last Name:BOLDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 JENKINS MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45692-9561
Mailing Address - Country:US
Mailing Address - Phone:740-384-3039
Mailing Address - Fax:740-384-3718
Practice Address - Street 1:142 JENKINS MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:OH
Practice Address - Zip Code:45692-9561
Practice Address - Country:US
Practice Address - Phone:740-384-3039
Practice Address - Fax:740-384-3718
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA04229224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant