Provider Demographics
NPI:1376862276
Name:BOLTON, EARLENE KATRICE
Entity Type:Individual
Prefix:
First Name:EARLENE
Middle Name:KATRICE
Last Name:BOLTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 OAK FOREST PARKWAY CT
Mailing Address - Street 2:APARTMENT F
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-1991
Mailing Address - Country:US
Mailing Address - Phone:314-609-4142
Mailing Address - Fax:
Practice Address - Street 1:1430 OLIVE ST
Practice Address - Street 2:SUITE 500
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-2303
Practice Address - Country:US
Practice Address - Phone:314-206-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator