Provider Demographics
NPI:1437714862
Name:BOLTON THERAPY & WELLNESS
Entity Type:Organization
Organization Name:BOLTON THERAPY & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DESYREE
Authorized Official - Middle Name:ALLISON
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:703-587-6738
Mailing Address - Street 1:1534 BOLTON ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-4203
Mailing Address - Country:US
Mailing Address - Phone:703-568-7398
Mailing Address - Fax:
Practice Address - Street 1:1534 BOLTON ST STE 1
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-4203
Practice Address - Country:US
Practice Address - Phone:703-568-7398
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health