Basic Information
Provider Information | |||||||||
NPI: | 1588080238 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOLDRIN | ||||||||
FirstName: | ALISHA | ||||||||
MiddleName: | ANNETTE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMHC, MHP, SUDP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CLAYTON | ||||||||
OtherFirstName: | ALISHA | ||||||||
OtherMiddleName: | ANNETTE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MA, LMHC, SUDP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4526 FEDERAL AVE | ||||||||
Address2: |   | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982032132 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253496200 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4526 FEDERAL AVE | ||||||||
Address2: |   | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982032132 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253496200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/05/2014 | ||||||||
LastUpdateDate: | 05/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP60145230 | WA | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | LH60668566 | WA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.