Provider Demographics
NPI:1417101627
Name:BOLTON, TRACEY L (MED BCBA)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:L
Last Name:BOLTON
Suffix:
Gender:F
Credentials:MED BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 LIGHTHOUSE PL
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-8353
Mailing Address - Country:US
Mailing Address - Phone:615-479-1713
Mailing Address - Fax:615-356-1843
Practice Address - Street 1:1245 LIGHTHOUSE PL
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-8353
Practice Address - Country:US
Practice Address - Phone:615-479-1713
Practice Address - Fax:615-356-1843
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-08-4137103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst