Provider Demographics
NPI:1811782618
Name:BOMAN, SAVANNAH
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:
Last Name:BOMAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:788 OLD GLORY WAY
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-5020
Mailing Address - Country:US
Mailing Address - Phone:626-428-7853
Mailing Address - Fax:
Practice Address - Street 1:788 OLD GLORY WAY
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-5020
Practice Address - Country:US
Practice Address - Phone:626-428-7853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-11
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician