Provider Demographics
NPI:1215586482
Name:BOLDEN, RAVEN
Entity Type:Individual
Prefix:MS
First Name:RAVEN
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 1:14680 NEWBURGH RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5034
Mailing Address - Country:US
Mailing Address - Phone:616-301-8000
Mailing Address - Fax:
Practice Address - Street 1:14680 NEWBURGH RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5034
Practice Address - Country:US
Practice Address - Phone:616-301-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician