Provider Demographics
NPI:1144805482
Name:BOLTON, MELISA
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:
Last Name:BOLTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 SKYLARK DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33327-2380
Mailing Address - Country:US
Mailing Address - Phone:540-922-1110
Mailing Address - Fax:775-392-1245
Practice Address - Street 1:3341 DUKE ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-5219
Practice Address - Country:US
Practice Address - Phone:703-870-3880
Practice Address - Fax:775-392-1245
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician