Provider Demographics
NPI:1083985733
Name:BOLTIN, KELLEY MARIE (MS LPC)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:MARIE
Last Name:BOLTIN
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S GILLETTE AVE STE 242
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-3741
Mailing Address - Country:US
Mailing Address - Phone:307-689-9090
Mailing Address - Fax:307-363-4339
Practice Address - Street 1:405 W BOXELDER RD STE C8
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-5320
Practice Address - Country:US
Practice Address - Phone:307-689-4185
Practice Address - Fax:307-689-4185
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1475101YP2500X
WYLPC 1475101YP2500X
WYPPC-651101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health