Provider Demographics
NPI:1023909454
Name:BOLTHOUSE, CRAIG (LLMSW)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:BOLTHOUSE
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-2231
Mailing Address - Country:US
Mailing Address - Phone:269-908-3646
Mailing Address - Fax:
Practice Address - Street 1:6070 NEWPORT RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-9234
Practice Address - Country:US
Practice Address - Phone:269-409-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851120030APP25101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health