Healthcare Provider Details

I. General information

NPI: 1962770685
Provider Name (Legal Business Name): KENNA CHRISTINE BOLTON HOLZ PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 04/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 EAST SECOND STREET
DULUTH MN
55805
US

IV. Provider business mailing address

400 E THIRD STREET MCL2CRED
DULUTH MN
55805-1951
US

V. Phone/Fax

Practice location:
  • Phone: 218-786-5360
  • Fax:
Mailing address:
  • Phone: 218-786-8319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2918-57
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5425
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: