Provider Demographics
NPI:1093588568
Name:BOSMA, MCKENZIE A (RBT)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:A
Last Name:BOSMA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1896 PALLADIAN DR APT 1323
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-7410
Mailing Address - Country:US
Mailing Address - Phone:765-615-5426
Mailing Address - Fax:
Practice Address - Street 1:1130 BOONE AIRE RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1202
Practice Address - Country:US
Practice Address - Phone:151-333-5074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-23-273485106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician