Healthcare Provider Details

I. General information

NPI: 1578264354
Provider Name (Legal Business Name): ERICA D BOLSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 TIMBER WAY CT
EATONTON GA
31024
US

IV. Provider business mailing address

109 TIMBER WAY CT
EATONTON GA
31024
US

V. Phone/Fax

Practice location:
  • Phone: 478-387-8057
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: