Provider Demographics
NPI:1053053561
Name:BOMBARD, EARL IV
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:
Last Name:BOMBARD
Suffix:IV
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 1:33 PUTNAM RD APT 8
Mailing Address - Street 2:
Mailing Address - City:FOXBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02035-2128
Mailing Address - Country:US
Mailing Address - Phone:802-355-4201
Mailing Address - Fax:
Practice Address - Street 1:33 PUTNAM RD APT 8
Practice Address - Street 2:
Practice Address - City:FOXBORO
Practice Address - State:MA
Practice Address - Zip Code:02035-2128
Practice Address - Country:US
Practice Address - Phone:802-355-4201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4295103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst