Provider Demographics
NPI:1316424955
Name:BOLDEN, MARCUS ANTHONY
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:ANTHONY
Last Name:BOLDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11324 WAGON PL
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79934-3373
Mailing Address - Country:US
Mailing Address - Phone:501-716-7960
Mailing Address - Fax:
Practice Address - Street 1:11324 WAGON PL
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79934-3373
Practice Address - Country:US
Practice Address - Phone:501-716-7960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician