Provider Demographics
NPI:1366575029
Name:BOLTON, MARTIN J (PHD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:J
Last Name:BOLTON
Suffix:
Gender:M
Credentials:PHD
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Other - Credentials:
Mailing Address - Street 1:760 BROADWAY DEPARTMENT OF MANAGED CARE ROOM 2B230
Mailing Address - Street 2:WOODHULL MENTAL & MEDICAL HEALTH CENTER
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206
Mailing Address - Country:US
Mailing Address - Phone:718-963-8000
Mailing Address - Fax:718-630-3122
Practice Address - Street 1:760 BROADWAY
Practice Address - Street 2:WOODHULL MENTAL & MEDICAL HEALTH CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206
Practice Address - Country:US
Practice Address - Phone:718-963-8000
Practice Address - Fax:718-260-7507
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY6887-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist