Provider Demographics
NPI:1427252592
Name:BOLDT, LISA ANN (COTA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:BOLDT
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:BECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1454 30TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-1312
Mailing Address - Country:US
Mailing Address - Phone:515-223-6620
Mailing Address - Fax:515-223-9625
Practice Address - Street 1:1454 30TH ST STE 103
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1312
Practice Address - Country:US
Practice Address - Phone:515-223-6620
Practice Address - Fax:515-223-9625
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00081224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant