Provider Demographics
NPI:1598545162
Name:BOUE, WILLDITH NIANA
Entity Type:Individual
Prefix:
First Name:WILLDITH
Middle Name:NIANA
Last Name:BOUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 N FEDERAL HWY STE 209
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-6722
Mailing Address - Country:US
Mailing Address - Phone:195-486-6143
Mailing Address - Fax:
Practice Address - Street 1:221 NE 22ND ST
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-4927
Practice Address - Country:US
Practice Address - Phone:786-782-1091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-300593106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician