=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568275766
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAYZHAUN BODKIN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2025
-----------------------------------------------------
Last Update Date | 01/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 WALDEMAR AVE APT 301
-----------------------------------------------------
City | EAST BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02128-1089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-964-5748
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 WALDEMAR AVE APT 301
-----------------------------------------------------
City | EAST BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02128-1089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 |
-----------------------------------------------------