MEDICARE: MS. DAPHNE RUTH BOLDEN APRN PMH CNS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	R087909	MD

General Provider Information

NPI Number	:	1073861886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DAPHNE RUTH BOLDEN APRN PMH CNS

Provider Business Mailing Address
First Line	:	1938 WINDER RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21244-1729
Country	:	US
Telephone Number	:	410-298-2609
Fax Number	:

Provider Business Practice Location Address
First Line	:	1938 WINDER RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21244-1729
Country	:	US
Telephone Number	:	410-298-2609
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2012
Last Update Date	:	10/12/2012

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