Healthcare Provider Details

I. General information

NPI: 1174002364
Provider Name (Legal Business Name): JUSTINE BARYE BOLTON PT, DPT, ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 SOUTH 291 HIGHWAY
INDEPENDENCE MO
64057
US

IV. Provider business mailing address

316 DAINS ST
LIBERTY MO
64068-2072
US

V. Phone/Fax

Practice location:
  • Phone: 816-373-9328
  • Fax: 816-373-9207
Mailing address:
  • Phone: 816-654-3748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2015028356
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2018028574
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: