Provider Demographics
NPI:1770212151
Name:BOLTON, KATHY
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:BOLTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 GRAND CENTRAL BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4146
Mailing Address - Country:US
Mailing Address - Phone:912-388-1035
Mailing Address - Fax:
Practice Address - Street 1:2451B US HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-3397
Practice Address - Country:US
Practice Address - Phone:912-312-7409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician