Provider Demographics
NPI:1174025282
Name:BOLDEN, CYNTHIA MECHELE
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:MECHELE
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 1:1041 ARMSBY WAY
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585-3702
Mailing Address - Country:US
Mailing Address - Phone:707-816-9880
Mailing Address - Fax:
Practice Address - Street 1:101 H ST STE L
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-5100
Practice Address - Country:US
Practice Address - Phone:707-835-7431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11550363OtherKAISER PERMANENTE
CA11550363OtherKAISER
CA11550363OtherKAISER PERMANENTA