Provider Demographics
NPI:1063232072
Name:DIOP, BOUSSO
Entity type:Individual
Prefix:
First Name:BOUSSO
Middle Name:
Last Name:DIOP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 HEATHER BROOK LN APT 807
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-5177
Mailing Address - Country:US
Mailing Address - Phone:469-494-2908
Mailing Address - Fax:
Practice Address - Street 1:2655 VILLA CREEK DR STE 140
Practice Address - Street 2:
Practice Address - City:FARMERS BRANCH
Practice Address - State:TX
Practice Address - Zip Code:75234-7385
Practice Address - Country:US
Practice Address - Phone:214-736-8376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-24-380996106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician