Provider Demographics
NPI:1720447634
Name:BOULWARE, GUSTY-LEE (PHD-BCBA-D)
Entity Type:Individual
Prefix:DR
First Name:GUSTY-LEE
Middle Name:
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:PHD-BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6239 WOODLAWN AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-5716
Mailing Address - Country:US
Mailing Address - Phone:206-271-4796
Mailing Address - Fax:206-729-2660
Practice Address - Street 1:6239 WOODLAWN AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-5716
Practice Address - Country:US
Practice Address - Phone:206-271-4796
Practice Address - Fax:206-729-2660
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1-02-0744103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1020744OtherBCBA