Provider Demographics
NPI:1104996859
Name:BOLTON, STANLEY NORRIS (MA LPC)
Entity type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:NORRIS
Last Name:BOLTON
Suffix:
Gender:M
Credentials:MA LPC
Other - Prefix:
Other - First Name:STAN
Other - Middle Name:N
Other - Last Name:BOLTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA LPC
Mailing Address - Street 1:1985 TATE BLVD SE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602
Mailing Address - Country:US
Mailing Address - Phone:828-326-5960
Mailing Address - Fax:828-328-4729
Practice Address - Street 1:1985 TATE BLVD SE
Practice Address - Street 2:SUITE 300
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602
Practice Address - Country:US
Practice Address - Phone:828-326-5960
Practice Address - Fax:828-328-4729
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2138101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102283Medicaid