Healthcare Provider Details

I. General information

NPI: 1043890304
Provider Name (Legal Business Name): MYCHAL BOLTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WALNUT ST
OWENSBORO KY
42301-2956
US

IV. Provider business mailing address

PO BOX 1637
OWENSBORO KY
42302-1637
US

V. Phone/Fax

Practice location:
  • Phone: 270-689-6500
  • Fax: 270-827-4671
Mailing address:
  • Phone: 270-689-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number02007052A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number06195
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: