Provider Demographics
NPI:1063519643
Name:BOLTON-FLYNN, CANDACE ANN (MS)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:ANN
Last Name:BOLTON-FLYNN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4590 MARSHA LN
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:WI
Mailing Address - Zip Code:53820-9683
Mailing Address - Country:US
Mailing Address - Phone:608-763-2973
Mailing Address - Fax:
Practice Address - Street 1:6058 S CHESTNUT ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-8947
Practice Address - Country:US
Practice Address - Phone:608-342-4863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1739-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39196200Medicaid