Provider Demographics
NPI:1871072082
Name:BOLTON, MELISSA (LLPC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BOLTON
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 N GAINSBOROUGH AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1937
Mailing Address - Country:US
Mailing Address - Phone:904-599-6281
Mailing Address - Fax:
Practice Address - Street 1:8623 N WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-1137
Practice Address - Country:US
Practice Address - Phone:734-367-0469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional