Provider Demographics
NPI:1588001515
Name:BOLDEN, KYNICKI ROSHA (DIPLOMA)
Entity Type:Individual
Prefix:
First Name:KYNICKI
Middle Name:ROSHA
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:DIPLOMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6214 OSAKA PEARL ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-2071
Mailing Address - Country:US
Mailing Address - Phone:702-845-5115
Mailing Address - Fax:
Practice Address - Street 1:2700 E SUNSET RD STE 7
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3507
Practice Address - Country:US
Practice Address - Phone:702-228-8788
Practice Address - Fax:702-832-0197
Is Sole Proprietor?:No
Enumeration Date:2013-05-31
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst