Provider Demographics
NPI:1144725698
Name:BOATMAN, AUDREY TAYLOR (MS, BCBA)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:TAYLOR
Last Name:BOATMAN
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8720 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-3079
Mailing Address - Country:US
Mailing Address - Phone:469-803-5655
Mailing Address - Fax:214-291-5692
Practice Address - Street 1:8720 MAIN ST
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-3079
Practice Address - Country:US
Practice Address - Phone:469-803-5655
Practice Address - Fax:214-291-5692
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-18-29822103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-18-29822OtherBEHAVIOR ANALYSIS CERTIFICATION BOARD