Healthcare Provider Details

I. General information

NPI: 1497278311
Provider Name (Legal Business Name): JONATHAN BOLDT LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2017
Last Update Date: 05/10/2024
Certification Date: 05/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 EL MOLINO BLVD
LAS CRUCES NM
88005-2915
US

IV. Provider business mailing address

350 EL MOLINO BLVD
LAS CRUCES NM
88005-2915
US

V. Phone/Fax

Practice location:
  • Phone: 575-449-2288
  • Fax: 575-267-6228
Mailing address:
  • Phone: 575-449-2288
  • Fax: 575-267-6228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH0208221
License Number StateNM

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: