Provider Demographics
NPI:1851063556
Name:BOLDT, BENJAMIN J (CSW)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:J
Last Name:BOLDT
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7012 RAASAF DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-4621
Mailing Address - Country:US
Mailing Address - Phone:575-649-9275
Mailing Address - Fax:575-267-6228
Practice Address - Street 1:350 EL MOLINO BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2915
Practice Address - Country:US
Practice Address - Phone:575-649-9275
Practice Address - Fax:575-267-6228
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor