Healthcare Provider Details

I. General information

NPI: 1720359672
Provider Name (Legal Business Name): HEATHER TATE BOLDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2012
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 FORUM PL 400 D & E
WEST PALM BEACH FL
33401-2319
US

IV. Provider business mailing address

323 52ND ST
WEST PALM BEACH FL
33407-2723
US

V. Phone/Fax

Practice location:
  • Phone: 561-616-8411
  • Fax:
Mailing address:
  • Phone: 786-385-3726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: