Provider Demographics
NPI:1992091169
Name:BOLDUC, KATHERINE A
Entity type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:A
Last Name:BOLDUC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 LYNN ST
Mailing Address - Street 2:2ND FLOOR REAR
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-5739
Mailing Address - Country:US
Mailing Address - Phone:978-648-1828
Mailing Address - Fax:
Practice Address - Street 1:96 LYNN ST
Practice Address - Street 2:2ND FLOOR REAR
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-5739
Practice Address - Country:US
Practice Address - Phone:978-648-1828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-25
Last Update Date:2011-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9305225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist