MEDICARE: CYNTHIA BOLDEN

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	103TC2200X	Clinical Child & Adolescent Psychologist
2	103TR0400X	Rehabilitation Psychologist

General Provider Information

NPI Number	:	1609298256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CYNTHIA BOLDEN

Provider Business Mailing Address
First Line	:	1957 SUSAN ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-2654
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1957 SUSAN ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-2654
Country	:	US
Telephone Number	:	702-812-2159
Fax Number	:

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

Provider Enumeration Date	:	01/16/2014
Last Update Date	:	01/16/2014

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Directions to “ CYNTHIA BOLDEN ” Practice Location

Language	Start Address	Practice Location

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