Healthcare Provider Details

I. General information

NPI: 1598214165
Provider Name (Legal Business Name): BOCAR DIENG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 HEATHERBRIDGE LN
BLACKLICK OH
43004-9269
US

IV. Provider business mailing address

131 HEATHERBRIDGE LN
BLACKLICK OH
43004-9269
US

V. Phone/Fax

Practice location:
  • Phone: 404-803-7080
  • Fax:
Mailing address:
  • Phone: 404-803-7080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberUK685720
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberUK685720
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: