Provider Demographics
NPI:1629474960
Name:BOLDEN, SHARON
Entity Type:Individual
Prefix:
First Name:SHARON
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 1:5506 GIST AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-4506
Mailing Address - Country:US
Mailing Address - Phone:443-802-0488
Mailing Address - Fax:
Practice Address - Street 1:2104 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5612
Practice Address - Country:US
Practice Address - Phone:410-752-6850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC9910101YM0800X
MDLCA1811172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health