Provider Demographics
NPI:1154199818
Name:BOLDT, MISTY (LMSW)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:BOLDT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:EAST ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14445-1358
Mailing Address - Country:US
Mailing Address - Phone:585-750-5208
Mailing Address - Fax:
Practice Address - Street 1:211 WALNUT ST
Practice Address - Street 2:
Practice Address - City:EAST ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14445-1358
Practice Address - Country:US
Practice Address - Phone:585-750-5208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096519101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health