Individual
DOUG BOLTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PH.D.
Contact information
Practice address
5100 N RAVENSWOOD AVE STE 225, CHICAGO, IL 60640-1752
(872) 241-9337
(872) 241-9338
Mailing address
5100 N RAVENSWOOD AVE STE 225, CHICAGO, IL 60640-1752
(872) 241-9337
(872) 241-9338
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
071005517
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
071005517
IDFPR
IL
Enumeration date
03/29/2019
Last updated
03/29/2019
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