MEDICARE: BETH BOLTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	72179	TX

General Provider Information

NPI Number	:	1649628942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETH BOLTON

Provider Business Mailing Address
First Line	:	3235 RIVER LODGE TRL N
Second Line	:	APARTMENT 239
City	:	FORT WORTH
State	:	TX
Zip	:	76116-0876
Country	:	US
Telephone Number	:	817-648-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3235 RIVER LODGE TRL N
Second Line	:	APARTMENT 239
City	:	FORT WORTH
State	:	TX
Zip	:	76116-0876
Country	:	US
Telephone Number	:	817-648-4000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2016
Last Update Date	:	05/26/2016

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Directions to “ BETH BOLTON ” Practice Location

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