Provider Demographics
NPI:1710588199
Name:BODDIE, ANTOINETTE LATRICE
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:LATRICE
Last Name:BODDIE
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 1:1727 BOXWOOD PL
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-2328
Mailing Address - Country:US
Mailing Address - Phone:706-569-0727
Mailing Address - Fax:
Practice Address - Street 1:1727 BOXWOOD PL
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-2328
Practice Address - Country:US
Practice Address - Phone:706-569-0727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty