Provider Demographics
NPI:1720437676
Name:BOLTON, KELLY ELIZABETH (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ELIZABETH
Last Name:BOLTON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 TULANE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-1534
Mailing Address - Country:US
Mailing Address - Phone:859-270-6356
Mailing Address - Fax:
Practice Address - Street 1:2250 THUNDERSTICK DR STE 1104
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505
Practice Address - Country:US
Practice Address - Phone:859-475-8352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-10
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7398104100000X
KY2534671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100556810Medicaid