Provider Demographics
NPI:1427231307
Name:MICHAEL BOLTWOOD , INC
Entity type:Organization
Organization Name:MICHAEL BOLTWOOD , INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLTWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:360-698-1321
Mailing Address - Street 1:PO BOX 2324
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-2324
Mailing Address - Country:US
Mailing Address - Phone:360-698-1321
Mailing Address - Fax:360-308-0447
Practice Address - Street 1:6000 WHALE DANCER CT NE
Practice Address - Street 2:
Practice Address - City:SUQUAMISH
Practice Address - State:WA
Practice Address - Zip Code:98392-9648
Practice Address - Country:US
Practice Address - Phone:360-698-1321
Practice Address - Fax:360-308-0447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001641103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7069149Medicaid
WAG8850229Medicare PIN