Provider Demographics
NPI:1306225842
Name:BOLDEN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
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 1:208 E THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-3316
Mailing Address - Country:US
Mailing Address - Phone:985-956-7823
Mailing Address - Fax:985-956-7824
Practice Address - Street 1:208 E THOMAS ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-3316
Practice Address - Country:US
Practice Address - Phone:985-956-7823
Practice Address - Fax:985-956-7824
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty