1235373515 NPI number — MS. MICHELLE BOLTON LPC-S

Table of content: MS. MICHELLE BOLTON LPC-S (NPI 1235373515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235373515 NPI number — MS. MICHELLE BOLTON LPC-S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLTON
Provider First Name:
MICHELLE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPC-S
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235373515
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1007 HIGHWAY 175
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHIL CAMPBELL
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35581-5859
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-769-1090
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14368 HIGHWAY 43 STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSSELLVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35653-2569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-291-7221
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/30/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  178.005944 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 180007883 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 3503 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)