Provider Demographics
NPI:1093460180
Name:BOLDUC, CONNOR
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:BOLDUC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 N SCOTTSDALE RD STE 2500
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-7630
Mailing Address - Country:US
Mailing Address - Phone:612-915-0049
Mailing Address - Fax:
Practice Address - Street 1:2103 COUNTY ROAD D E STE B
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-5358
Practice Address - Country:US
Practice Address - Phone:612-915-0049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4468101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional