Provider Demographics
NPI:1366521007
Name:NEWBOLT, JOAN ANTONIA (MS, LMFT)
Entity type:Individual
Prefix:MS
First Name:JOAN
Middle Name:ANTONIA
Last Name:NEWBOLT
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14950 JUNIPER RIDGE DR NW
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303-4222
Mailing Address - Country:US
Mailing Address - Phone:763-427-0441
Mailing Address - Fax:763-421-5646
Practice Address - Street 1:2006 1ST AVE STE B10
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-2255
Practice Address - Country:US
Practice Address - Phone:763-421-7909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN579106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN50038-01Medicare UPIN
MN103T2NEMedicare UPIN
MN62-33699Medicare UPIN
MN106989Medicare UPIN