Provider Demographics
NPI:1174002364
Name:BOLTON, JUSTINE BARYE (PT, DPT, ATC, LAT)
Entity Type:Individual
Prefix:MISS
First Name:JUSTINE
Middle Name:BARYE
Last Name:BOLTON
Suffix:
Gender:F
Credentials:PT, DPT, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 DAINS ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-2072
Mailing Address - Country:US
Mailing Address - Phone:816-654-3748
Mailing Address - Fax:
Practice Address - Street 1:2301 SOUTH 291 HIGHWAY
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057
Practice Address - Country:US
Practice Address - Phone:816-373-9328
Practice Address - Fax:816-373-9207
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150283562255A2300X
MO2018028574225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer