Provider Demographics
NPI:1710577663
Name:BOULANGER, ALEXANDRA (RBT)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:BOULANGER
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 CECIL G COSTIN SR BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-1754
Mailing Address - Country:US
Mailing Address - Phone:850-227-1163
Mailing Address - Fax:
Practice Address - Street 1:528 CECIL G COSTIN SR BLVD, SUITE A
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-3245
Practice Address - Country:US
Practice Address - Phone:850-227-1163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty