Provider Demographics
NPI:1932221850
Name:BOLCH, MARTHA CAMILLA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:CAMILLA
Last Name:BOLCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 PARKER BND
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78734-6330
Mailing Address - Country:US
Mailing Address - Phone:512-263-9453
Mailing Address - Fax:
Practice Address - Street 1:1106 CLAYTON LN
Practice Address - Street 2:STE. 445E
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-1066
Practice Address - Country:US
Practice Address - Phone:512-323-6994
Practice Address - Fax:512-323-6990
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX611908Medicare ID - Type UnspecifiedSOCIAL WORKER