Healthcare Provider Details

I. General information

NPI: 1669817698
Provider Name (Legal Business Name): AVON D BODDIN SPECIAL EDUCATION
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AVON D BODDIN SPECIAL EDUCATION

II. Dates (important events)

Enumeration Date: 05/03/2013
Last Update Date: 05/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88-48 78 STREET
WOODHAVEN NY
11421
US

IV. Provider business mailing address

8848 78TH ST
WOODHAVEN NY
11421-2310
US

V. Phone/Fax

Practice location:
  • Phone: 718-296-8810
  • Fax:
Mailing address:
  • Phone: 718-296-8810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number693099121
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: