MEDICARE: THERESAH BOATENG 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	1-21-53459	NM

General Provider Information

NPI Number	:	1780126094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESAH BOATENG BCBA

Provider Business Mailing Address
First Line	:	8300 JEFFERSON ST NE STE B
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87113-1734
Country	:	US
Telephone Number	:	844-743-6506
Fax Number	:

Provider Business Practice Location Address
First Line	:	8300 JEFFERSON ST NE STE B
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87113-1734
Country	:	US
Telephone Number	:	844-743-6506
Fax Number	:

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

Provider Enumeration Date	:	11/17/2016
Last Update Date	:	03/29/2023

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