Provider Demographics
NPI:1619952694
Name:BOETTCHER, CAROLINE A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CAROLINE
Middle Name:A
Last Name:BOETTCHER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:CAROLINE
Other - Middle Name:A
Other - Last Name:BOETTCHER-MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:24 GRANT PL
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-5922
Mailing Address - Country:US
Mailing Address - Phone:631-495-8413
Mailing Address - Fax:631-412-5571
Practice Address - Street 1:24 GRANT PL
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-5922
Practice Address - Country:US
Practice Address - Phone:631-495-8413
Practice Address - Fax:631-412-5571
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2011-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015284103TC2200X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool