Provider Demographics
NPI:1427357615
Name:BOLTON, KEVIN LEE (MT-BC, LPC, MHSP)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LEE
Last Name:BOLTON
Suffix:
Gender:M
Credentials:MT-BC, LPC, MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 S CHURCH ST STE 805
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37130-4983
Mailing Address - Country:US
Mailing Address - Phone:615-624-4481
Mailing Address - Fax:
Practice Address - Street 1:745 S CHURCH ST STE 805
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-4983
Practice Address - Country:US
Practice Address - Phone:615-624-4481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-28
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225A00000X
TNLPC0000005266101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional