Provider Demographics
NPI:1881426583
Name:BOLTON, ELIZABETH ANN
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
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 1:414 E FLORAL AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-2914
Mailing Address - Country:US
Mailing Address - Phone:260-726-9341
Mailing Address - Fax:
Practice Address - Street 1:414 E FLORAL AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-2914
Practice Address - Country:US
Practice Address - Phone:260-726-9341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1566098103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool