MEDICARE: BOLD HORIZONS THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker

General Provider Information

NPI Number	:	1265374433
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOLD HORIZONS THERAPY LLC

Provider Business Mailing Address
First Line	:	PO BOX 10
Second Line	:
City	:	MASON
State	:	MI
Zip	:	48854-0010
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2703 DELLRIDGE DR
Second Line	:
City	:	HOLT
State	:	MI
Zip	:	48842-9718
Country	:	US
Telephone Number	:	810-938-9931
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	MARY BETH HOUPT
Credential	:
Telephone Number	:	517-676-9797

Provider Enumeration Date	:	04/07/2026
Last Update Date	:	04/07/2026

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