Provider Demographics
NPI:1386783926
Name:BOLT, PAUL ALLEN (OTR)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ALLEN
Last Name:BOLT
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 MID CITIES DR
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4270
Mailing Address - Country:US
Mailing Address - Phone:870-404-1046
Mailing Address - Fax:
Practice Address - Street 1:34 DUNN LN
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-8663
Practice Address - Country:US
Practice Address - Phone:870-425-5597
Practice Address - Fax:870-425-5592
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2017-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR411225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR124621721Medicaid