Provider Demographics
NPI:1497321897
Name:BOULTON, KIRSTEN CATHELL (LCSW)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:CATHELL
Last Name:BOULTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 PINE AVE APT 134
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4598
Mailing Address - Country:US
Mailing Address - Phone:760-221-4017
Mailing Address - Fax:
Practice Address - Street 1:550 ORANGE ST STE F
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-3242
Practice Address - Country:US
Practice Address - Phone:760-221-4017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALSCW283851041C0700X
CA28385104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker