Provider Demographics
NPI:1336987387
Name:BOLTON, DIERDRE LEMON BLOSSOM
Entity type:Individual
Prefix:
First Name:DIERDRE
Middle Name:LEMON BLOSSOM
Last Name:BOLTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 N CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-8208
Mailing Address - Country:US
Mailing Address - Phone:561-306-1783
Mailing Address - Fax:
Practice Address - Street 1:2000 N CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-8208
Practice Address - Country:US
Practice Address - Phone:561-306-1783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor