Provider Demographics
NPI:1386705176
Name:BOLTON, LYNDA BROOKS (PHD)
Entity type:Individual
Prefix:
First Name:LYNDA
Middle Name:BROOKS
Last Name:BOLTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 450
Mailing Address - Street 2:
Mailing Address - City:ORCHARD HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30266-0450
Mailing Address - Country:US
Mailing Address - Phone:770-229-9324
Mailing Address - Fax:770-229-9796
Practice Address - Street 1:2914 MACON ROAD
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224
Practice Address - Country:US
Practice Address - Phone:770-229-9324
Practice Address - Fax:770-229-9796
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY000828103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00261027AMedicaid