Provider Demographics
NPI:1841963824
Name:BOLSTON, MAX (COTA)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:BOLSTON
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8028 RITCHIE HWY
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-1075
Mailing Address - Country:US
Mailing Address - Phone:410-766-1995
Mailing Address - Fax:
Practice Address - Street 1:1051 BRIGHTSEAT RD
Practice Address - Street 2:
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20785-3738
Practice Address - Country:US
Practice Address - Phone:240-487-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02662225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist