Healthcare Provider Details

I. General information

NPI: 1528128238
Provider Name (Legal Business Name): ELIZABETH JANE BOLT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SOUTHEASTERN MENTAL HEALTH AUTHORITY 401 W THAMES ST BLDG 301
NORWICH CT
06380
US

IV. Provider business mailing address

SOUTHEASTERN MENTAL HEALTH AUTHORITY 401 W THAMES ST BLDG 301
NORWICH CT
06380
US

V. Phone/Fax

Practice location:
  • Phone: 860-859-4674
  • Fax: 860-859-4790
Mailing address:
  • Phone: 860-859-4674
  • Fax: 860-859-4790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number003387
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: