Provider Demographics
NPI:1821893249
Name:BOUBACAR, KAIDIAN (MSW)
Entity type:Individual
Prefix:
First Name:KAIDIAN
Middle Name:
Last Name:BOUBACAR
Suffix:
Gender:
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1947 NW 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-2451
Mailing Address - Country:US
Mailing Address - Phone:347-400-1030
Mailing Address - Fax:
Practice Address - Street 1:1314 E LAS OLAS BLVD # 1590
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2334
Practice Address - Country:US
Practice Address - Phone:954-560-4279
Practice Address - Fax:954-522-5174
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW192641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical