Basic Information
| Provider Information | |||||||||
| NPI: | 1811341555 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLSTAD | ||||||||
| FirstName: | ORIN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 820068 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414762373 | ||||||||
| FaxNumber: | 5414761526 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 SW G. STREET | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975262544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414762373 | ||||||||
| FaxNumber: | 5414761526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2016 | ||||||||
| LastUpdateDate: | 05/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 374 | OR | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.