Provider Demographics
NPI:1144352790
Name:BOLTON, STACI S (PSYD)
Entity type:Individual
Prefix:DR
First Name:STACI
Middle Name:S
Last Name:BOLTON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5755 N POINT PKWY
Mailing Address - Street 2:SUITE 65
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-1142
Mailing Address - Country:US
Mailing Address - Phone:770-591-5501
Mailing Address - Fax:770-591-5502
Practice Address - Street 1:5755 N POINT PKWY
Practice Address - Street 2:SUITE 65
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-1142
Practice Address - Country:US
Practice Address - Phone:770-591-5501
Practice Address - Fax:770-591-5502
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2925103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist