Provider Demographics
NPI:1538768593
Name:BOLDT, MICHELLE RAE (LMHC-T)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RAE
Last Name:BOLDT
Suffix:
Gender:F
Credentials:LMHC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 E STATE ST STE 301
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-3309
Mailing Address - Country:US
Mailing Address - Phone:641-421-2089
Mailing Address - Fax:641-450-0030
Practice Address - Street 1:103 E STATE ST STE 301
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-3309
Practice Address - Country:US
Practice Address - Phone:641-421-2089
Practice Address - Fax:641-450-0030
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101349101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional