Provider Demographics
NPI:1073378063
Name:BOULWARE, DANIQUA TISHAWN (LCSW)
Entity Type:Individual
Prefix:
First Name:DANIQUA
Middle Name:TISHAWN
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 LEE ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-3839
Mailing Address - Country:US
Mailing Address - Phone:704-487-4000
Mailing Address - Fax:
Practice Address - Street 1:116 LEE ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3839
Practice Address - Country:US
Practice Address - Phone:704-487-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0175581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical