Provider Demographics
NPI:1235373515
Name:BOLTON, MICHELLE (LPC-S)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:BOLTON
Suffix:
Gender:F
Credentials:LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 HIGHWAY 175
Mailing Address - Street 2:
Mailing Address - City:PHIL CAMPBELL
Mailing Address - State:AL
Mailing Address - Zip Code:35581-5859
Mailing Address - Country:US
Mailing Address - Phone:847-769-1090
Mailing Address - Fax:
Practice Address - Street 1:14368 HIGHWAY 43 STE 1
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-2569
Practice Address - Country:US
Practice Address - Phone:256-291-7221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-30
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.005944101YP2500X
IL180007883101YP2500X
AL3503101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional