MEDICARE: NICHOLAS BOLTON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	12267030-3501	UT

General Provider Information

NPI Number	:	1245916204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS BOLTON LCSW

Provider Business Mailing Address
First Line	:	8420 S WASATCH BLVD
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8420 S WASATCH BLVD
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121
Country	:	US
Telephone Number	:	503-460-7410
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2023
Last Update Date	:	06/26/2023

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