MEDICARE: DEBRA BOELDT PH.D.

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	103TC0700X	Clinical Psychologist	27292	CA

General Provider Information

NPI Number	:	1548638653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBRA BOELDT PH.D.

Provider Business Mailing Address
First Line	:	4570 EXECUTIVE DR
Second Line	:	SUITE 100
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-3074
Country	:	US
Telephone Number	:	858-253-1732
Fax Number	:

Provider Business Practice Location Address
First Line	:	4570 EXECUTIVE DR
Second Line	:	SUITE 100
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-3074
Country	:	US
Telephone Number	:	858-253-1732
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2015
Last Update Date	:	09/04/2015

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