Provider Demographics
NPI:1073747762
Name:BOLDRIDGE, RICHARD ALAN
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALAN
Last Name:BOLDRIDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MONTEBELLO RD STE 202
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1366
Mailing Address - Country:US
Mailing Address - Phone:719-545-2746
Mailing Address - Fax:719-542-9638
Practice Address - Street 1:41 MONTEBELLO RD STE LL1
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001
Practice Address - Country:US
Practice Address - Phone:719-545-2746
Practice Address - Fax:719-542-9638
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0014104101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional