Provider Demographics
NPI:1053799510
Name:BOLTON, MELISSA DAWN
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:DAWN
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 1:22001 NORTHPARK DR STE 400
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-3809
Mailing Address - Country:US
Mailing Address - Phone:381-223-5300
Mailing Address - Fax:
Practice Address - Street 1:1720 NICHOLSON DR APT 10
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802-8135
Practice Address - Country:US
Practice Address - Phone:225-324-9360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-15
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
TX4843103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist