Provider Demographics
NPI:1942592316
Name:BOLTS-KRICK, LESA M
Entity Type:Individual
Prefix:
First Name:LESA
Middle Name:M
Last Name:BOLTS-KRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LESA
Other - Middle Name:M
Other - Last Name:BOLTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:543 WHIDBY ST # A
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:543 WHIDBY ST # A
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6547
Practice Address - Country:US
Practice Address - Phone:360-582-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60045627225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant