Healthcare Provider Details

I. General information

NPI: 1184656951
Provider Name (Legal Business Name): SANDRA P BOLTAX-STERN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 ANSONIA RD
WOODBRIDGE CT
06525-2502
US

IV. Provider business mailing address

78 ANSONIA RD
WOODBRIDGE CT
06525-2502
US

V. Phone/Fax

Practice location:
  • Phone: 203-387-3403
  • Fax:
Mailing address:
  • Phone: 203-387-3403
  • Fax: 203-387-9125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License NumberCT11608
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberCT11608
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code364SP0810X
TaxonomyChild & Family Psychiatric/Mental Health Clinical Nurse Specialist
License NumberCT11608
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: