Provider Demographics
NPI:1912510074
Name:BOOST BEHAVIORAL SERVICES LLC
Entity Type:Organization
Organization Name:BOOST BEHAVIORAL SERVICES LLC
Other - Org Name:BOOST BEHAVIORAL SERVICES LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEZE
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:912-655-9431
Mailing Address - Street 1:174 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5324
Mailing Address - Country:US
Mailing Address - Phone:912-655-9431
Mailing Address - Fax:
Practice Address - Street 1:14B MARSHELLEN DR
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6900
Practice Address - Country:US
Practice Address - Phone:843-400-4581
Practice Address - Fax:843-400-4024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-28
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty