Provider Demographics
NPI:1164128625
Name:BOLTON, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BOLTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CANAVERAL
Mailing Address - State:FL
Mailing Address - Zip Code:32920-5204
Mailing Address - Country:US
Mailing Address - Phone:313-258-4137
Mailing Address - Fax:
Practice Address - Street 1:549 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:CAPE CANAVERAL
Practice Address - State:FL
Practice Address - Zip Code:32920-5204
Practice Address - Country:US
Practice Address - Phone:313-258-4137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICC-0C4150341544103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist