Provider Demographics
NPI:1922109156
Name:BOLDT, ROSEANNE MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROSEANNE
Middle Name:MARIE
Last Name:BOLDT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 ROBERT PARKER COFFIN RD
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047
Mailing Address - Country:US
Mailing Address - Phone:847-821-1459
Mailing Address - Fax:847-359-7673
Practice Address - Street 1:211 ROBERT PARKER COFFIN RD
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047
Practice Address - Country:US
Practice Address - Phone:847-821-1459
Practice Address - Fax:847-359-7673
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004907383OtherBCBS