Provider Demographics
NPI:1487739694
Name:BOLTWOOD, MICHAEL (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BOLTWOOD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2324
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-2324
Mailing Address - Country:US
Mailing Address - Phone:360-698-1321
Mailing Address - Fax:360-308-0447
Practice Address - Street 1:6000 WHALE DANCER CT NE
Practice Address - Street 2:
Practice Address - City:SUQUAMISH
Practice Address - State:WA
Practice Address - Zip Code:98392-9648
Practice Address - Country:US
Practice Address - Phone:360-698-1321
Practice Address - Fax:360-308-0447
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7069149Medicaid
G8850230Medicare PIN