Provider Demographics
NPI:1922011097
Name:BOLT, MARY D (AUD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:D
Last Name:BOLT
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3945 OKEMOS RD
Mailing Address - Street 2:STE B1
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-4207
Mailing Address - Country:US
Mailing Address - Phone:517-349-0200
Mailing Address - Fax:517-349-3030
Practice Address - Street 1:310 N CLIPPERT ST
Practice Address - Street 2:STE 4
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4694
Practice Address - Country:US
Practice Address - Phone:517-332-1691
Practice Address - Fax:517-324-0210
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI1601000086231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI804679861Medicaid
MI540C312880OtherBCBS HEARING AIDS
MI640C326130OtherBCBS SERVICES
MIN89310003Medicare ID - Type Unspecified