Provider Demographics
NPI:1104659630
Name:BOLSTER, DIANE BRADFORD (MSW, LCSWA)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:BRADFORD
Last Name:BOLSTER
Suffix:
Gender:
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 ROLLING HILL RD STE 225
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8861
Mailing Address - Country:US
Mailing Address - Phone:980-505-7712
Mailing Address - Fax:
Practice Address - Street 1:121 ROLLING HILL RD STE 225
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8861
Practice Address - Country:US
Practice Address - Phone:704-737-2109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPO211831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty