Healthcare Provider Details

I. General information

NPI: 1790084044
Provider Name (Legal Business Name): P'SHANA QUOTI BOLDEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2011
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 FRUITVALE AVE
OAKLAND CA
94601-2313
US

IV. Provider business mailing address

848 FAN PALM LN
BRENTWOOD CA
94513-5680
US

V. Phone/Fax

Practice location:
  • Phone: 510-434-2001
  • Fax:
Mailing address:
  • Phone: 909-730-4592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number62906
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: