MEDICARE: MARK BOOZER M. ED., BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-12-12594	FL

General Provider Information

NPI Number	:	1558771592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK BOOZER M. ED., BCBA

Provider Business Mailing Address
First Line	:	903 RANCH FLS
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78245-3577
Country	:	US
Telephone Number	:	210-788-1340
Fax Number	:

Provider Business Practice Location Address
First Line	:	5522 LONE STAR PKWY STE 101
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78253-6719
Country	:	US
Telephone Number	:	210-670-8028
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2014
Last Update Date	:	12/18/2019

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