Provider Demographics
NPI:1558771592
Name:BOOZER, MARK (M ED, BCBA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BOOZER
Suffix:
Gender:M
Credentials:M ED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 RANCH FLS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-3577
Mailing Address - Country:US
Mailing Address - Phone:210-788-1340
Mailing Address - Fax:
Practice Address - Street 1:5522 LONE STAR PKWY STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-6719
Practice Address - Country:US
Practice Address - Phone:210-670-8028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-12-12594103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst