Healthcare Provider Details

I. General information

NPI: 1336696665
Provider Name (Legal Business Name): SHIRLEY BOLTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 1ST ST
GILROY CA
95020-4733
US

IV. Provider business mailing address

PO BOX 127
NAPA CA
94559-0127
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone: 707-255-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110847
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: