Provider Demographics
NPI:1952500621
Name:VANBOLDEN, EMANUEL T (PHD LP)
Entity Type:Individual
Prefix:DR
First Name:EMANUEL
Middle Name:T
Last Name:VANBOLDEN
Suffix:
Gender:M
Credentials:PHD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42335 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-5040
Mailing Address - Country:US
Mailing Address - Phone:248-333-1083
Mailing Address - Fax:
Practice Address - Street 1:42335 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-5040
Practice Address - Country:US
Practice Address - Phone:248-333-1083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011393103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical