Provider Demographics
NPI:1508248113
Name:BOLTON, MELANIE DANIELLE (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:DANIELLE
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 1:215 MAPLE ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4609
Mailing Address - Country:US
Mailing Address - Phone:505-410-8873
Mailing Address - Fax:
Practice Address - Street 1:215 MAPLE ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4609
Practice Address - Country:US
Practice Address - Phone:505-410-8873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1-21-47337103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst