Provider Demographics
NPI:1891224820
Name:BOLT, ALLYSON SUE (LMSW)
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:SUE
Last Name:BOLT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 ERICA LN
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-2256
Mailing Address - Country:US
Mailing Address - Phone:616-915-6899
Mailing Address - Fax:
Practice Address - Street 1:743 N MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48915-2057
Practice Address - Country:US
Practice Address - Phone:517-927-8346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-04
Last Update Date:2017-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010929931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical