MEDICARE: MATTHEW BOLDEN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	110611	TX

General Provider Information

NPI Number	:	1043086853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW BOLDEN LCSW

Provider Business Mailing Address
First Line	:	5608 AVENUE F APT 258
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78751-1260
Country	:	US
Telephone Number	:	985-212-0384
Fax Number	:

Provider Business Practice Location Address
First Line	:	5608 AVENUE F APT 258
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78751-1260
Country	:	US
Telephone Number	:	985-212-0384
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2023
Last Update Date	:	12/01/2023

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