Healthcare Provider Details

I. General information

NPI: 1528608403
Provider Name (Legal Business Name): LISA JOY BOLDEN MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2020
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52125 VIA CASTILE
LA QUINTA CA
92253-7816
US

IV. Provider business mailing address

79125 CORPORATE CENTER DR UNIT 6143
LA QUINTA CA
92248-4055
US

V. Phone/Fax

Practice location:
  • Phone: 310-990-1515
  • Fax: 855-825-1502
Mailing address:
  • Phone: 310-990-1515
  • Fax: 855-825-1502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number11543
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: