Provider Demographics
NPI:1124590633
Name:BOLDEN, LECRETIA
Entity Type:Individual
Prefix:
First Name:LECRETIA
Middle Name:
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25151 ZEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44132-1806
Mailing Address - Country:US
Mailing Address - Phone:216-858-0724
Mailing Address - Fax:
Practice Address - Street 1:3622 PROSPECT AVE E
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2704
Practice Address - Country:US
Practice Address - Phone:216-431-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)