Healthcare Provider Details

I. General information

NPI: 1033304233
Provider Name (Legal Business Name): KIRSTEN W BOLTON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 02/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MILL ST
BELMONT MA
02478-1064
US

IV. Provider business mailing address

115 MILL ST
BELMONT MA
02478-1064
US

V. Phone/Fax

Practice location:
  • Phone: 617-855-4194
  • Fax:
Mailing address:
  • Phone: 617-855-4194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number116529
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: