Provider Demographics
NPI:1174200018
Name:BOLDEN, MICAH (LCSW)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:BOLDEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 HAINES AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-4042
Mailing Address - Country:US
Mailing Address - Phone:706-333-3426
Mailing Address - Fax:
Practice Address - Street 1:1139 HAINES AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-4042
Practice Address - Country:US
Practice Address - Phone:706-333-3426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-03
Last Update Date:2025-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1079151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical