Provider Demographics
NPI:1053438150
Name:BOLDEN, KIMALA WINGER (MACCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KIMALA
Middle Name:WINGER
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 IVORY STREET
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506
Mailing Address - Country:US
Mailing Address - Phone:337-504-2498
Mailing Address - Fax:337-504-4961
Practice Address - Street 1:232 IVORY STREET
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506
Practice Address - Country:US
Practice Address - Phone:504-554-0765
Practice Address - Fax:337-504-4961
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3248235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist