=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407335797
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLA BOLTON LCMHC, NCC, CCTP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2018
-----------------------------------------------------
Last Update Date | 10/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2813 EASTOVER NORTH DR FAYETTEVILLE NC 28312-6705
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-571-6706
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2813 EASTOVER NORTH DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28312-3981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-571-6706
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 16811
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------