Provider Demographics
NPI:1659039949
Name:BODA, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:BODA
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 1:4085 PINELLA CIR APT 627
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-6737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8785 SW 165TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-5827
Practice Address - Country:US
Practice Address - Phone:561-421-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician