Provider Demographics
NPI:1013217660
Name:EMANUEL T. VANBOLDEN, PHD, LP, PC
Entity Type:Organization
Organization Name:EMANUEL T. VANBOLDEN, PHD, LP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMANUEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:VANBOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-333-1083
Mailing Address - Street 1:42335 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-5040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 FARNSWORTH ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-4060
Practice Address - Country:US
Practice Address - Phone:313-577-2840
Practice Address - Fax:313-577-8949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013909251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health