Provider Demographics
NPI:1710671748
Name:BOUNDLESS BEHAVIORAL LLC
Entity Type:Organization
Organization Name:BOUNDLESS BEHAVIORAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:JERMAINE
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-992-3607
Mailing Address - Street 1:3495 ENGLISH OAKS DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5794
Mailing Address - Country:US
Mailing Address - Phone:470-992-3607
Mailing Address - Fax:678-401-8381
Practice Address - Street 1:3495 ENGLISH OAKS DR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5794
Practice Address - Country:US
Practice Address - Phone:470-992-3607
Practice Address - Fax:678-401-8381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty