Provider Demographics
NPI:1457715260
Name:BOETTCHER, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:BOETTCHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 PINENUT DR
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75181-2900
Mailing Address - Country:US
Mailing Address - Phone:605-290-4803
Mailing Address - Fax:
Practice Address - Street 1:1111 S MAIN ST
Practice Address - Street 2:SUITE 210
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-5577
Practice Address - Country:US
Practice Address - Phone:214-563-5909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1-15-20633103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst