Provider Demographics
NPI:1326759648
Name:BOLT, KEVIN R (LPC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:BOLT
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 FM 995
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:TX
Mailing Address - Zip Code:75551-6412
Mailing Address - Country:US
Mailing Address - Phone:903-733-2743
Mailing Address - Fax:
Practice Address - Street 1:300 E 6TH ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-5207
Practice Address - Country:US
Practice Address - Phone:870-772-0156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80934101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor