Healthcare Provider Details

I. General information

NPI: 1457625592
Provider Name (Legal Business Name): AMANDA MICHELE BOLTE CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2012
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S DEER RD
MACOMB IL
61455-2639
US

IV. Provider business mailing address

2323 WINDISH DR
GALESBURG IL
61401-9780
US

V. Phone/Fax

Practice location:
  • Phone: 309-837-4876
  • Fax: 309-833-1531
Mailing address:
  • Phone: 309-344-2323
  • Fax: 309-344-4368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number29487
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: