Healthcare Provider Details

I. General information

NPI: 1265825608
Provider Name (Legal Business Name): MARTIN PAUL BOLDIN JR. LICSW, MLADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2015
Last Update Date: 03/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 REUBENS DRIFTWAY
HAMPTON NH
03842-2389
US

IV. Provider business mailing address

1 REUBENS DRIFTWAY
HAMPTON NH
03842-2389
US

V. Phone/Fax

Practice location:
  • Phone: 603-785-0785
  • Fax:
Mailing address:
  • Phone: 603-785-0785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number0512
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1021
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: