Provider Demographics
NPI:1891275525
Name:BOLTON, CYNTHIA MAE
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:MAE
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 1:1192 E DRAPER PKWY # 447
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9356
Mailing Address - Country:US
Mailing Address - Phone:562-544-8654
Mailing Address - Fax:
Practice Address - Street 1:1192 E DRAPER PARKWAY # 447
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020
Practice Address - Country:US
Practice Address - Phone:562-544-8654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA170190614103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool