Provider Demographics
NPI:1508221375
Name:BOLDEN LIPPETT, SHIRLEY A (AS)
Entity Type:Individual
Prefix:MISS
First Name:SHIRLEY
Middle Name:A
Last Name:BOLDEN LIPPETT
Suffix:
Gender:F
Credentials:AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 E VERNOR HWY
Mailing Address - Street 2:APT 413
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-2744
Mailing Address - Country:US
Mailing Address - Phone:313-895-0500
Mailing Address - Fax:313-895-9503
Practice Address - Street 1:2150 E VERNOR HWY
Practice Address - Street 2:APT 413
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-2744
Practice Address - Country:US
Practice Address - Phone:313-895-0500
Practice Address - Fax:313-895-9503
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)