Healthcare Provider Details

I. General information

NPI: 1649945114
Provider Name (Legal Business Name): LEA J BOLDT PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWKINS DR
IOWA CITY IA
52242-1009
US

IV. Provider business mailing address

200 HAWKINS DR
IOWA CITY IA
52242-1009
US

V. Phone/Fax

Practice location:
  • Phone: 319-356-4658
  • Fax: 319-356-2587
Mailing address:
  • Phone: 319-356-4658
  • Fax: 319-356-2587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number109669
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number109669
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number109669
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number109669
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number109669
License Number StateIA
# 6
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number109669
License Number StateIA
# 7
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number109669
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: