=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033258215
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES SAMUEL BOLDT M.S.W.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 344 LUPINE WAY
-----------------------------------------------------
City | VENTURA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93001-2221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-643-4357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 344 LUPINE WAY
-----------------------------------------------------
City | VENTURA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93001-2221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-643-4357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCS 5728
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------