Provider Demographics
NPI:1386313005
Name:BOLDS, ALYCIA MARSHELL
Entity type:Individual
Prefix:
First Name:ALYCIA
Middle Name:MARSHELL
Last Name:BOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3316 HUDSON AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-3168
Mailing Address - Country:US
Mailing Address - Phone:330-937-7197
Mailing Address - Fax:
Practice Address - Street 1:3316 HUDSON AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44511-3168
Practice Address - Country:US
Practice Address - Phone:330-937-7197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty