Provider Demographics
NPI:1013412675
Name:BOLDEN, CIERRA (LSW)
Entity Type:Individual
Prefix:
First Name:CIERRA
Middle Name:
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2251 TIMBER LN
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-4532
Mailing Address - Country:US
Mailing Address - Phone:330-439-3212
Mailing Address - Fax:
Practice Address - Street 1:2251 TIMBER LN
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-4532
Practice Address - Country:US
Practice Address - Phone:330-439-3212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
OH104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician