Provider Demographics
NPI:1881999647
Name:BOLT, TERESA Y (LPCC-S)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:Y
Last Name:BOLT
Suffix:
Gender:F
Credentials:LPCC-S
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:Y
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCC-S
Mailing Address - Street 1:80 SUNBURY RD
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-3062
Mailing Address - Country:US
Mailing Address - Phone:740-637-9768
Mailing Address - Fax:
Practice Address - Street 1:5982 RHODES RD
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-8100
Practice Address - Country:US
Practice Address - Phone:330-676-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0900362SUPV101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0301050Medicaid