=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194359950
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ATKA BOL CONSTANT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2020
-----------------------------------------------------
Last Update Date | 10/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 194 PLEASANT ST STE 2
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03301-2952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-471-7791
-----------------------------------------------------
Fax | 877-754-5246
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 446 MICOL RD
-----------------------------------------------------
City | PEMBROKE
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03275-3114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-858-2350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 12476404
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------