Provider Demographics
NPI:1780076109
Name:BOLT, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BOLT
Suffix:
Gender:F
Credentials:
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 343
Mailing Address - Street 2:
Mailing Address - City:NORTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01534-0343
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43 SUTTON ST
Practice Address - Street 2:APARTMENT B
Practice Address - City:NORTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01534-1081
Practice Address - Country:US
Practice Address - Phone:774-327-5160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor