Provider Demographics
NPI:1639549587
Name:BOLDEN, TABITHA (MS)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9806 LINCOLN CT
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-2427
Mailing Address - Country:US
Mailing Address - Phone:219-384-7444
Mailing Address - Fax:
Practice Address - Street 1:9806 LINCOLN CT
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-2427
Practice Address - Country:US
Practice Address - Phone:219-384-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health