Provider Demographics
NPI:1295272425
Name:BOLDEN, TIANA (MASSAGE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:TIANA
Middle Name:
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:MASSAGE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 1/2 S PEARL ST
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-3329
Mailing Address - Country:US
Mailing Address - Phone:509-929-3163
Mailing Address - Fax:
Practice Address - Street 1:399 E YAKIMA AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-4519
Practice Address - Country:US
Practice Address - Phone:509-225-4772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60637644225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist