Provider Demographics
NPI:1902577083
Name:BOXLEY, BRIDGETT RENAE (PHD)
Entity Type:Individual
Prefix:
First Name:BRIDGETT
Middle Name:RENAE
Last Name:BOXLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:BRIDGETT
Other - Middle Name:RENAE
Other - Last Name:TATE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:16903 RED OAK DR STE 110
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-3966
Mailing Address - Country:US
Mailing Address - Phone:713-907-7716
Mailing Address - Fax:
Practice Address - Street 1:16903 RED OAK DR STE 213
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-3915
Practice Address - Country:US
Practice Address - Phone:713-907-7716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022048270103TC0700X
TX40067103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical