Provider Demographics
NPI:1477342954
Name:BOLDEN, ANGEL TYQUALA
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:TYQUALA
Last Name:BOLDEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 VANTAGE WAY
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29611-7575
Mailing Address - Country:US
Mailing Address - Phone:864-361-9851
Mailing Address - Fax:
Practice Address - Street 1:937 VANTAGE WAY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-7575
Practice Address - Country:US
Practice Address - Phone:864-361-9851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst