MEDICARE: MS. MARTHA LEIGH BOLTON L.C.S.W

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	1041C0700X	Clinical Social Worker	0232	OK

General Provider Information

NPI Number	:	1750517066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARTHA LEIGH BOLTON L.C.S.W

Provider Business Mailing Address
First Line	:	10017 S PENNSYLVANIA AVE
Second Line	:	SUITE A
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-6919
Country	:	US
Telephone Number	:	405-759-3880
Fax Number	:	405-759-3882

Provider Business Practice Location Address
First Line	:	10017 S PENNSYLVANIA AVE
Second Line	:	SUITE A
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-6919
Country	:	US
Telephone Number	:	405-759-3880
Fax Number	:	405-759-3882

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

Provider Enumeration Date	:	06/02/2009
Last Update Date	:	06/02/2009

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