Healthcare Provider Details

I. General information

NPI: 1407511660
Provider Name (Legal Business Name): BOLDEN THERAPY & WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 KRAFT DR STE 1300
BLACKSBURG VA
24060-6162
US

IV. Provider business mailing address

2000 KRAFT DR STE 1300
BLACKSBURG VA
24060-6162
US

V. Phone/Fax

Practice location:
  • Phone: 540-880-2208
  • Fax: 540-866-0868
Mailing address:
  • Phone: 540-880-2208
  • Fax: 540-866-0868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHAMEKA BOLDEN
Title or Position: DIRECTOR OF CLINICAL SERVICES
Credential: LPC
Phone: 540-880-2208