Provider Demographics
NPI:1306221411
Name:BOATNER, KENNETH CARTER (EDD,MPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:CARTER
Last Name:BOATNER
Suffix:
Gender:M
Credentials:EDD,MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 PEACHTREE ST NE UNIT 1407
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2277
Mailing Address - Country:US
Mailing Address - Phone:617-784-3535
Mailing Address - Fax:
Practice Address - Street 1:565 PEACHTREE STREET, N.E.
Practice Address - Street 2:SUITE 1407
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2277
Practice Address - Country:US
Practice Address - Phone:617-784-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003786103T00000X
MA4286103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist