Provider Demographics
NPI:1124433776
Name:BOEHM, MARTHA LOUISE (MED, BCBA)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:LOUISE
Last Name:BOEHM
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:LOUISE
Other - Last Name:ANLAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11953 OLDFIELD POINTE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-3512
Mailing Address - Country:US
Mailing Address - Phone:904-578-7767
Mailing Address - Fax:904-578-7845
Practice Address - Street 1:8700 ROLLING BROOK LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9024
Practice Address - Country:US
Practice Address - Phone:904-716-3065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FL1-17-27477103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist