Provider Demographics
NPI:1164091377
Name:BOLING-TAYLOR, SHANDA LYNETTE (MSW)
Entity Type:Individual
Prefix:
First Name:SHANDA
Middle Name:LYNETTE
Last Name:BOLING-TAYLOR
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-1219
Mailing Address - Country:US
Mailing Address - Phone:618-283-2222
Mailing Address - Fax:
Practice Address - Street 1:403 N 42ND ST STE C
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2297
Practice Address - Country:US
Practice Address - Phone:618-283-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker