Provider Demographics
NPI:1184668170
Name:BOLTON, OWEN L (LMSW)
Entity Type:Individual
Prefix:MR
First Name:OWEN
Middle Name:L
Last Name:BOLTON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W. FERRY ST
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-4866
Mailing Address - Country:US
Mailing Address - Phone:269-883-6560
Mailing Address - Fax:269-883-6891
Practice Address - Street 1:2775 W DICKMAN RD
Practice Address - Street 2:P1
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49037-4866
Practice Address - Country:US
Practice Address - Phone:269-883-6560
Practice Address - Fax:269-883-6891
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010655501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical