Provider Demographics
NPI:1427101617
Name:BOLTON, DAVID (MED, LPC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BOLTON
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 BLANDWOOD AVE.
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401
Mailing Address - Country:US
Mailing Address - Phone:336-389-1413
Mailing Address - Fax:336-389-1416
Practice Address - Street 1:12 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4537
Practice Address - Country:US
Practice Address - Phone:910-765-1003
Practice Address - Fax:910-765-1004
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC906101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC16497OtherBLUE CROSS BLUE SHIELD
NC6102305Medicaid