Provider Demographics
NPI:1104952381
Name:BOLTAS, DEBRA (PHD)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:BOLTAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-2417
Mailing Address - Country:US
Mailing Address - Phone:203-824-4476
Mailing Address - Fax:
Practice Address - Street 1:66 TRUMBULL ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-1012
Practice Address - Country:US
Practice Address - Phone:203-787-9119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001924103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical