Healthcare Provider Details

I. General information

NPI: 1669662847
Provider Name (Legal Business Name): ELEANOR THOMSON BOLDRICK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3270 KERNER BLVD STE B
SAN RAFAEL CA
94901-4840
US

IV. Provider business mailing address

3270 KERNER BLVD STE B
SAN RAFAEL CA
94901-4840
US

V. Phone/Fax

Practice location:
  • Phone: 415-473-6806
  • Fax: 415-473-6313
Mailing address:
  • Phone: 415-473-6806
  • Fax: 415-473-6313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00004077
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 26406
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: