Provider Demographics
NPI:1730653460
Name:BOLDIN, TRACY LYNN (BS, QMHP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:BOLDIN
Suffix:
Gender:F
Credentials:BS, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 90521
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90009-0521
Mailing Address - Country:US
Mailing Address - Phone:214-549-8769
Mailing Address - Fax:
Practice Address - Street 1:840 N AVENUE 66
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-1508
Practice Address - Country:US
Practice Address - Phone:626-395-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101Y00000XBehavioral Health & Social Service ProvidersCounselor