Provider Demographics
NPI:1730777087
Name:DR. EDYTHE BOULDIN, LPC
Entity type:Organization
Organization Name:DR. EDYTHE BOULDIN, LPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDYTHE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BOULDIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:804-647-5564
Mailing Address - Street 1:2025 E MAIN ST STE 204
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-7073
Mailing Address - Country:US
Mailing Address - Phone:804-647-5564
Mailing Address - Fax:
Practice Address - Street 1:2025 E MAIN ST STE 204
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-7073
Practice Address - Country:US
Practice Address - Phone:804-647-5564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)