Provider Demographics
NPI:1659828960
Name:BOLDEN, MARANDA
Entity Type:Individual
Prefix:
First Name:MARANDA
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 1:4906 MERLIN CIR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-4526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4906 MERLIN CIRCLE
Practice Address - Street 2:APT 4906
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71108
Practice Address - Country:US
Practice Address - Phone:682-276-9850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor