Provider Demographics
NPI:1770721391
Name:BOLTE, TERRYL A (LSW)
Entity type:Individual
Prefix:
First Name:TERRYL
Middle Name:A
Last Name:BOLTE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 E BISMARCK EXPY
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-6577
Mailing Address - Country:US
Mailing Address - Phone:701-255-2773
Mailing Address - Fax:701-255-6261
Practice Address - Street 1:1120 LARAMIE DR
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-6373
Practice Address - Country:US
Practice Address - Phone:701-222-1952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3104171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator