Provider Demographics
NPI:1932794245
Name:B.O.L.D.L.Y. THERAPY A MARRIAGE AND FAMILY THERAPY PROFESSIONAL CORPOR
Entity Type:Organization
Organization Name:B.O.L.D.L.Y. THERAPY A MARRIAGE AND FAMILY THERAPY PROFESSIONAL CORPOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:NYCOLE
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:323-639-0558
Mailing Address - Street 1:3200 E GUASTI RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-8661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3200 E GUASTI RD STE 100
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-8661
Practice Address - Country:US
Practice Address - Phone:323-639-0558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)