Provider Demographics
NPI:1639630718
Name:BOLTON, DOUG (PHD)
Entity Type:Individual
Prefix:
First Name:DOUG
Middle Name:
Last Name:BOLTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 N RAVENSWOOD AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1752
Mailing Address - Country:US
Mailing Address - Phone:872-241-9337
Mailing Address - Fax:872-241-9338
Practice Address - Street 1:5100 N RAVENSWOOD AVE STE 225
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1752
Practice Address - Country:US
Practice Address - Phone:872-241-9337
Practice Address - Fax:872-241-9338
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005517103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071005517OtherIDFPR