Provider Demographics
NPI:1790279974
Name:BOLDEN, CHARIS
Entity Type:Individual
Prefix:
First Name:CHARIS
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 1:8250 N GRAND CANYON DR UNIT 1140
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89166-3738
Mailing Address - Country:US
Mailing Address - Phone:702-717-4880
Mailing Address - Fax:
Practice Address - Street 1:2580 N RANCHO DR STE 105
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3361
Practice Address - Country:US
Practice Address - Phone:702-982-3636
Practice Address - Fax:702-982-3737
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst