Provider Demographics
NPI:1861760696
Name:BOLTON, KESHA (MA,CCC-SLP)
Entity type:Individual
Prefix:
First Name:KESHA
Middle Name:
Last Name:BOLTON
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13333 WEST RD
Mailing Address - Street 2:#1521
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-6082
Mailing Address - Country:US
Mailing Address - Phone:281-469-7170
Mailing Address - Fax:
Practice Address - Street 1:16214 WILMINGTON PARK LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-1962
Practice Address - Country:US
Practice Address - Phone:713-640-5671
Practice Address - Fax:832-427-1374
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101626235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist