Provider Demographics
NPI:1629890413
Name:BOLTON, SHELBY
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:BOLTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3228 UNIVERSITY AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-7263
Mailing Address - Country:US
Mailing Address - Phone:706-992-6866
Mailing Address - Fax:706-992-6867
Practice Address - Street 1:3228 UNIVERSITY AVE STE 105
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-7263
Practice Address - Country:US
Practice Address - Phone:706-992-6866
Practice Address - Fax:706-992-6867
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
GAMT011280225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist