Provider Demographics
NPI:1306275326
Name:BOLTON, MIRINDA A (LPC)
Entity type:Individual
Prefix:MRS
First Name:MIRINDA
Middle Name:A
Last Name:BOLTON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 RICHLAND ST STE B101
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2357
Mailing Address - Country:US
Mailing Address - Phone:803-403-8469
Mailing Address - Fax:803-403-9979
Practice Address - Street 1:914 RICHLAND ST STE B101
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2357
Practice Address - Country:US
Practice Address - Phone:803-403-8469
Practice Address - Fax:803-403-9979
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5611101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional