Provider Demographics
NPI:1497082267
Name:BOLTON, AMY K (MA)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:K
Last Name:BOLTON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2242 W JEFFERSON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2275
Mailing Address - Country:US
Mailing Address - Phone:734-250-3919
Mailing Address - Fax:
Practice Address - Street 1:2242 W JEFFERSON AVE STE A
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-2275
Practice Address - Country:US
Practice Address - Phone:734-250-3919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011716103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical