Provider Demographics
NPI:1245940568
Name:BOULWARE, ANNA TAYLOR (LCMHCA, NCC, APTT)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:TAYLOR
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:LCMHCA, NCC, APTT
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCMHCA, NCC, APTT
Mailing Address - Street 1:11610 EASTWIND DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-3687
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11610 EASTWIND DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-3687
Practice Address - Country:US
Practice Address - Phone:919-613-4594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15895101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional