MEDICARE: DR. LAURA ROSE BOLTE PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	129227	KY
2	103T00000X	Psychologist	129227	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366493298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA ROSE BOLTE PH.D.

Provider Business Mailing Address
First Line	:	305 ARTILLERY PARK DR UNIT 102
Second Line	:
City	:	FORT MITCHELL
State	:	KY
Zip	:	41017-2794
Country	:	US
Telephone Number	:	859-426-0200
Fax Number	:	859-426-0042

Provider Business Practice Location Address
First Line	:	305 ARTILLERY PARK DR UNIT 102
Second Line	:
City	:	FORT MITCHELL
State	:	KY
Zip	:	41017-2794
Country	:	US
Telephone Number	:	859-426-0200
Fax Number	:	859-426-0042

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	04/08/2019

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