Provider Demographics
NPI:1487043980
Name:BOUNDLESS POTENTIAL, LLC
Entity Type:Organization
Organization Name:BOUNDLESS POTENTIAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:MENZEL
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:325-338-6182
Mailing Address - Street 1:926 SQUARE DANCE LN
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-4160
Mailing Address - Country:US
Mailing Address - Phone:325-338-6182
Mailing Address - Fax:
Practice Address - Street 1:926 SQUARE DANCE LN
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-4160
Practice Address - Country:US
Practice Address - Phone:325-338-6182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
11416922103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty