MEDICARE: ASHLEY BOLDT

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	224Z00000X	Occupational Therapy Assistant	4648-27	WI

General Provider Information

NPI Number	:	1558614321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY BOLDT

Provider Business Mailing Address
First Line	:	4220 PITTCO RD
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54313-8757
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 1ST ST
Second Line	:
City	:	OCONTO
State	:	WI
Zip	:	54153-1117
Country	:	US
Telephone Number	:	920-834-4575
Fax Number	:

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

Provider Enumeration Date	:	10/18/2012
Last Update Date	:	10/18/2012

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Directions to “ ASHLEY BOLDT ” Practice Location

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