Provider Demographics
NPI:1003531930
Name:BOATNER, DRU VICTORIA
Entity Type:Individual
Prefix:
First Name:DRU
Middle Name:VICTORIA
Last Name:BOATNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 28TH AVE SW STE 2
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:IA
Mailing Address - Zip Code:50009-3940
Mailing Address - Country:US
Mailing Address - Phone:563-554-3225
Mailing Address - Fax:515-644-4134
Practice Address - Street 1:950 28TH AVE SW STE 2
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:IA
Practice Address - Zip Code:50009-3940
Practice Address - Country:US
Practice Address - Phone:515-644-4134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22-204131106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician