Provider Demographics
NPI:1295437234
Name:BOLDEN, LASHASTA K
Entity type:Individual
Prefix:
First Name:LASHASTA
Middle Name:K
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 1:245 MURDOCK CV
Mailing Address - Street 2:
Mailing Address - City:RIDGELY
Mailing Address - State:TN
Mailing Address - Zip Code:38080-1509
Mailing Address - Country:US
Mailing Address - Phone:731-259-7738
Mailing Address - Fax:
Practice Address - Street 1:118 HALLIBURTON ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:TN
Practice Address - Zip Code:38063-2011
Practice Address - Country:US
Practice Address - Phone:731-635-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3767224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant