Healthcare Provider Details

I. General information

NPI: 1770509556
Provider Name (Legal Business Name): MARY ANN BOLKOVATZ CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4710 TABLE MESA DR STE B
BOULDER CO
80305-4504
US

IV. Provider business mailing address

4710 TABLE MESA DR STE B
BOULDER CO
80305-4504
US

V. Phone/Fax

Practice location:
  • Phone: 303-261-5037
  • Fax: 888-466-0439
Mailing address:
  • Phone: 303-261-5037
  • Fax: 888-466-0439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number67698
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: