Provider Demographics
NPI:1760231070
Name:BOLDEN, LA DONNA MICHELLE
Entity type:Individual
Prefix:
First Name:LA DONNA
Middle Name:MICHELLE
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 1:6241 S EBERHART AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-3318
Mailing Address - Country:US
Mailing Address - Phone:404-441-9053
Mailing Address - Fax:
Practice Address - Street 1:6241 S EBERHART AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-3318
Practice Address - Country:US
Practice Address - Phone:404-441-9053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist