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General NPI Number Information
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NPI Number | 1588627038
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Entity Type | Individual
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Provider Name | MARY BETH BOULDEN LCSW, LPC
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Gender | Female
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Dates
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Enumeration Date | 04/07/2006
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Last Update Date | 10/03/2007
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Provider Practice Location Address
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Address Line | 5501 OLD YORK RD MOSS 1, OFFICE 139
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City | PHILADELPHIA
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State | PA
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Zip | 19141-3018
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Country | US
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Telephone | 215-456-9884
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Fax |
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Provider Business Mailing Address
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Address Line | 3015 DARBY RD
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City | ARDMORE
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State | PA
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Zip | 19003-1623
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Country | US
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Telephone | 610-449-1969
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | PC000160
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | SW124663
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License Number State | PA
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