Provider Demographics
NPI:1619391216
Name:BOEHM, COREY AMANDA (MED, BCBA)
Entity Type:Individual
Prefix:MS
First Name:COREY
Middle Name:AMANDA
Last Name:BOEHM
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4510 SALT LAKE BLVD STE D8
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-3172
Mailing Address - Country:US
Mailing Address - Phone:808-591-6060
Mailing Address - Fax:
Practice Address - Street 1:4510 SALT LAKE BLVD STE D8
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96818-3172
Practice Address - Country:US
Practice Address - Phone:808-591-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
HIBA-42103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst