Provider Demographics
NPI:1710332796
Name:BOLDEN, CHARMAINE
Entity Type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARMAINE
Other - Middle Name:
Other - Last Name:CLEMENTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1717 KINGS GLEN LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76140-5784
Mailing Address - Country:US
Mailing Address - Phone:817-779-2406
Mailing Address - Fax:
Practice Address - Street 1:1531 HIGHLAND COLONY PKWY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-7469
Practice Address - Country:US
Practice Address - Phone:601-352-7784
Practice Address - Fax:601-968-0021
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst