Healthcare Provider Details

I. General information

NPI: 1235373515
Provider Name (Legal Business Name): MICHELLE BOLTON LPC-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2009
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14368 HIGHWAY 43 STE 1
RUSSELLVILLE AL
35653-2569
US

IV. Provider business mailing address

1007 HIGHWAY 175
PHIL CAMPBELL AL
35581-5859
US

V. Phone/Fax

Practice location:
  • Phone: 256-291-7221
  • Fax:
Mailing address:
  • Phone: 847-769-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.005944
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180007883
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3503
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: