Provider Demographics
NPI:1427551860
Name:BOLD HEARTS AND SOUND MINDS LLC
Entity type:Organization
Organization Name:BOLD HEARTS AND SOUND MINDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:ABIGAIL
Authorized Official - Last Name:BOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, LADC, CCTP
Authorized Official - Phone:405-757-1777
Mailing Address - Street 1:PO BOX 1992
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-1992
Mailing Address - Country:US
Mailing Address - Phone:405-757-1777
Mailing Address - Fax:405-805-6352
Practice Address - Street 1:1360 S FRETZ DR STE 107
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-5869
Practice Address - Country:US
Practice Address - Phone:405-757-1777
Practice Address - Fax:405-805-6351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-12
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5008261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200374260AMedicaid