=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851601421
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOLDUC EMPLOYMENT SUPPORT & TRAINING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2010
-----------------------------------------------------
Last Update Date | 10/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 175 LANCASTER STREET SUITE 218A
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-774-8700
-----------------------------------------------------
Fax | 207-774-8700
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 175 LANCASTER STREET SUITE 218A
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-774-8700
-----------------------------------------------------
Fax | 207-774-8700
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | LAURA J BOLDUC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 207-774-8700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------