Provider Demographics
NPI:1023198975
Name:BOLTON-OWENS, MARY (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BOLTON-OWENS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4312 MARKWOOD LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3638
Mailing Address - Country:US
Mailing Address - Phone:301-260-9762
Mailing Address - Fax:
Practice Address - Street 1:12359 SUNRISE VALLEY DR
Practice Address - Street 2:SUITE 220
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-3462
Practice Address - Country:US
Practice Address - Phone:301-620-9762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003162101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional