Provider Demographics
NPI:1891937447
Name:BOLDA, CLARENCE GEORGE JR (MS, LLMFT)
Entity Type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:GEORGE
Last Name:BOLDA
Suffix:JR
Gender:M
Credentials:MS, LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5361 SEQUOIA CT
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-3502
Mailing Address - Country:US
Mailing Address - Phone:810-742-4341
Mailing Address - Fax:
Practice Address - Street 1:901 CHIPPEWA ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-1570
Practice Address - Country:US
Practice Address - Phone:810-232-9950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-28
Last Update Date:2009-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1469109106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist