Healthcare Provider Details

I. General information

NPI: 1437714862
Provider Name (Legal Business Name): BOLTON THERAPY & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1534 BOLTON ST STE 1
BALTIMORE MD
21217-4203
US

IV. Provider business mailing address

1534 BOLTON ST STE 1
BALTIMORE MD
21217-4203
US

V. Phone/Fax

Practice location:
  • Phone: 703-568-7398
  • Fax:
Mailing address:
  • Phone: 703-568-7398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. DESYREE ALLISON DIXON
Title or Position: THERAPIST
Credential: LCSW-C
Phone: 703-587-6738