MEDICARE: KESHA BOLTON M.A.,CCC-SLP

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	235Z00000X	Speech-Language Pathologist	101626	TX

General Provider Information

NPI Number	:	1861760696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KESHA BOLTON M.A.,CCC-SLP

Provider Business Mailing Address
First Line	:	13333 WEST RD
Second Line	:	#1521
City	:	HOUSTON
State	:	TX
Zip	:	77041-6082
Country	:	US
Telephone Number	:	281-469-7170
Fax Number	:

Provider Business Practice Location Address
First Line	:	16214 WILMINGTON PARK LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77084-1962
Country	:	US
Telephone Number	:	713-640-5671
Fax Number	:	832-427-1374

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

Provider Enumeration Date	:	12/07/2011
Last Update Date	:	12/07/2011

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