=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346853579
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA BOLTON LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2020
-----------------------------------------------------
Last Update Date | 04/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 399 CREEKS JEWELL DR
-----------------------------------------------------
City | RINGGOLD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30736-6761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-635-3146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 399 CREEKS JEWELL DR
-----------------------------------------------------
City | RINGGOLD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30736-6761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC009870
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------