Provider Demographics
NPI:1942598107
Name:BOLDT, GINA M (LMT)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:M
Last Name:BOLDT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12740 KOEPSEL RD
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:NY
Mailing Address - Zip Code:14001-9628
Mailing Address - Country:US
Mailing Address - Phone:716-442-5442
Mailing Address - Fax:
Practice Address - Street 1:400 INTERNATIONAL DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5760
Practice Address - Country:US
Practice Address - Phone:716-631-1516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020181-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist