Provider Demographics
NPI:1104331768
Name:BOLT, PEYTON LIGHTNING
Entity type:Individual
Prefix:
First Name:PEYTON
Middle Name:LIGHTNING
Last Name:BOLT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 AUSTIN PL
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-5472
Mailing Address - Country:US
Mailing Address - Phone:386-846-8407
Mailing Address - Fax:
Practice Address - Street 1:741 AUSTIN PL
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-5472
Practice Address - Country:US
Practice Address - Phone:386-846-8407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst