Basic Information
| Provider Information | |||||||||
| NPI: | 1396048534 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | BOLDT | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOLDT | ||||||||
| OtherFirstName: | ALICIA | ||||||||
| OtherMiddleName: | THERESE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 350 PEE DEE AVE | ||||||||
| Address2: | |||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280014932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049861500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5700 EXECUTIVE CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282128858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045253255 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2010 | ||||||||
| LastUpdateDate: | 12/27/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C007246 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.