Provider Demographics
NPI:1043995236
Name:BOLDEN, MACHELLE
Entity type:Individual
Prefix:
First Name:MACHELLE
Middle Name:
Last Name:BOLDEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 WELLS AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-3837
Mailing Address - Country:US
Mailing Address - Phone:864-725-4673
Mailing Address - Fax:
Practice Address - Street 1:1033 EDGEFIELD ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-3205
Practice Address - Country:US
Practice Address - Phone:864-227-3908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-16
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10731101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC421504Medicaid
SC3335OtherMEDICARE