Provider Demographics
NPI:1750365946
Name:BOLTON, JUDY (LPC)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:BOLTON
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 1:1502 E AIRLINE RD
Mailing Address - Street 2:SUITE 25
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-4154
Mailing Address - Country:US
Mailing Address - Phone:361-575-0611
Mailing Address - Fax:
Practice Address - Street 1:1502 E AIRLINE RD
Practice Address - Street 2:SUITE 25
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-4154
Practice Address - Country:US
Practice Address - Phone:361-575-0611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19203101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168640401Medicaid