Provider Demographics
NPI:1336899780
Name:BOLDT, MOLLY LEIGH (BT)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:LEIGH
Last Name:BOLDT
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1526
Mailing Address - Street 2:
Mailing Address - City:BRUSH PRAIRIE
Mailing Address - State:WA
Mailing Address - Zip Code:98606-0047
Mailing Address - Country:US
Mailing Address - Phone:360-624-6059
Mailing Address - Fax:
Practice Address - Street 1:4101 SE 192ND AVE # 101
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-1471
Practice Address - Country:US
Practice Address - Phone:360-605-1881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABOLDTML991KM106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician