Provider Demographics
NPI:1891061800
Name:BOLDRIDGE, DEANN LYNN
Entity Type:Individual
Prefix:
First Name:DEANN
Middle Name:LYNN
Last Name:BOLDRIDGE
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 1:1108 SUMMERFIELD CT
Mailing Address - Street 2:
Mailing Address - City:ATCHISON
Mailing Address - State:KS
Mailing Address - Zip Code:66002-9548
Mailing Address - Country:US
Mailing Address - Phone:913-426-6971
Mailing Address - Fax:
Practice Address - Street 1:509 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:ATCHISON
Practice Address - State:KS
Practice Address - Zip Code:66002-2418
Practice Address - Country:US
Practice Address - Phone:913-360-0129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-24
Last Update Date:2012-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS767101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)