Provider Demographics
NPI:1073084950
Name:BOULOGNE, ZAIDA YADIRA
Entity Type:Individual
Prefix:
First Name:ZAIDA
Middle Name:YADIRA
Last Name:BOULOGNE
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 1:58 PARK PL
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-2333
Mailing Address - Country:US
Mailing Address - Phone:908-357-3169
Mailing Address - Fax:
Practice Address - Street 1:58 PARK PL
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-2333
Practice Address - Country:US
Practice Address - Phone:908-357-3169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2021-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst