Provider Demographics
NPI:1639556962
Name:BOLDEN-MCCOY, AQUEELAH F (PSS)
Entity Type:Individual
Prefix:
First Name:AQUEELAH
Middle Name:F
Last Name:BOLDEN-MCCOY
Suffix:
Gender:F
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:620 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:971-274-3757
Practice Address - Fax:503-912-5740
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60487815101Y00000X
OR101YM0800X
ORTHW000002697101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor