Provider Demographics
NPI:1780037481
Name:BOLTON, ANNA (DPT)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:BOLTON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N MCCLURG CT APT 2215
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4343
Mailing Address - Country:US
Mailing Address - Phone:913-707-4343
Mailing Address - Fax:
Practice Address - Street 1:929 W FOSTER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1491
Practice Address - Country:US
Practice Address - Phone:773-433-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-053832251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics