Healthcare Provider Details

I. General information

NPI: 1023198975
Provider Name (Legal Business Name): MARY BOLTON-OWENS L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12359 SUNRISE VALLEY DR SUITE 220
RESTON VA
20191-3462
US

IV. Provider business mailing address

4312 MARKWOOD LN
FAIRFAX VA
22033-3638
US

V. Phone/Fax

Practice location:
  • Phone: 301-620-9762
  • Fax:
Mailing address:
  • Phone: 301-260-9762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701003162
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: