Provider Demographics
NPI:1659785129
Name:BOLDEN, GWENDOLYN
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
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 1:7326 MYSTERY RDG
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-2727
Mailing Address - Country:US
Mailing Address - Phone:210-862-8211
Mailing Address - Fax:
Practice Address - Street 1:4615 WALZEM ROAD
Practice Address - Street 2:207
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78218
Practice Address - Country:US
Practice Address - Phone:210-862-8211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner