Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 553MP | LA |
Y | 103TC0700X | Clinical Psychologist | 553MP | LA |
N | 103TP0016X | Prescribing (Medical) | 553MP | LA |
NPI | 1003805102 |
---|---|
Provider Name | John F Bolter |
First Address | Baton Rouge, LA 70884-9509 |
Second Address | Baton Rouge, LA 70810-1686 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/10/2005 |
Last Update Date | 15/05/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
R77217 | (02) | LA |