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General NPI Number Information
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NPI Number | 1659099117
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Entity Type | Individual
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Provider Name | DOMINIC EDWARD BOEHNKE
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Gender | Male
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Dates
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Enumeration Date | 08/19/2022
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Last Update Date | 08/19/2022
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Provider Practice Location Address
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Address Line | 180 CENTER PLACE WAY
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City | ST AUGUSTINE
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State | FL
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Zip | 32095-8859
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Country | US
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Telephone | 904-240-2179
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Fax |
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Provider Business Mailing Address
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Address Line | 2439 HAMPTON FALLS DR W
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City | JACKSONVILLE
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State | FL
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Zip | 32224-3873
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | RBT-22-228771
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License Number State | FL
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