Provider Demographics
NPI:1457672362
Name:BOLDEN, TAMIKA S
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:S
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 1:2760 DORA AVE.
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778
Mailing Address - Country:US
Mailing Address - Phone:352-742-7837
Mailing Address - Fax:352-742-7837
Practice Address - Street 1:2760 DORA AVE.
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778
Practice Address - Country:US
Practice Address - Phone:352-742-7837
Practice Address - Fax:352-742-7837
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11164224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant