Provider Demographics
NPI:1023608825
Name:BOLDEN, SIMONE KENDALL (LCSW)
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:KENDALL
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SIMONE
Other - Middle Name:KENDALL
Other - Last Name:INGRAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:9250 COLUMBIA AVE STE 2E
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3530
Mailing Address - Country:US
Mailing Address - Phone:219-595-0043
Mailing Address - Fax:219-237-2894
Practice Address - Street 1:9250 COLUMBIA AVE STE 2E
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3530
Practice Address - Country:US
Practice Address - Phone:219-595-0043
Practice Address - Fax:219-237-2894
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490239381041C0700X
IN34009011A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical