Provider Demographics
NPI:1093213456
Name:FLETCHER, ANTHONY RICHARD
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:RICHARD
Last Name:FLETCHER
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 1:234 W BANDERA RD # 325
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-2805
Mailing Address - Country:US
Mailing Address - Phone:225-505-8024
Mailing Address - Fax:
Practice Address - Street 1:2525 LADD ST
Practice Address - Street 2:
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-5308
Practice Address - Country:US
Practice Address - Phone:210-447-7041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15-02331106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician