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General NPI Number Information
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NPI Number | 1710332796
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Entity Type | Individual
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Provider Name | CHARMAINE BOLDEN
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Gender | Female
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Dates
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Enumeration Date | 04/27/2016
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Last Update Date | 10/25/2018
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Provider Practice Location Address
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Address Line | 1531 HIGHLAND COLONY PKWY
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City | MADISON
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State | MS
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Zip | 39110-7469
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Country | US
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Telephone | 601-352-7784
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Fax | 601-968-0021
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Provider Business Mailing Address
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Address Line | 1717 KINGS GLEN LN
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City | FORT WORTH
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State | TX
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Zip | 76140-5784
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Country | US
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Telephone | 817-779-2406
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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 | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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