Provider Demographics
NPI:1548724164
Name:BOLDEN, HEATHER LEE
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEE
Last Name:BOLDEN
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 1:1316 ARMAND DR APT 201
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-8953
Mailing Address - Country:US
Mailing Address - Phone:865-585-3816
Mailing Address - Fax:
Practice Address - Street 1:177 N HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-4747
Practice Address - Country:US
Practice Address - Phone:901-325-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6410225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6410OtherSTATE OF TENNESSEE