Provider Demographics
NPI:1043817240
Name:BOOTMAN, ERIC J
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:BOOTMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-3529
Mailing Address - Country:US
Mailing Address - Phone:978-409-5360
Mailing Address - Fax:
Practice Address - Street 1:6225 SMITH AVE STE 1001A
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3626
Practice Address - Country:US
Practice Address - Phone:482-487-7576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician