Provider Demographics
NPI:1760747604
Name:BOLTON-JOHNSON, TONYA (LPC)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:BOLTON-JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 N LEE AVE STE 214
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-2620
Mailing Address - Country:US
Mailing Address - Phone:405-160-3435
Mailing Address - Fax:405-516-0344
Practice Address - Street 1:111 N LEE
Practice Address - Street 2:214
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103
Practice Address - Country:US
Practice Address - Phone:405-516-0343
Practice Address - Fax:405-516-0344
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5421101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200436920AMedicaid
OK1760747604OtherNPI