Provider Demographics
NPI:1194173104
Name:BOATMAN, MICHELLE GLENDA (MA CIT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GLENDA
Last Name:BOATMAN
Suffix:
Gender:F
Credentials:MA CIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 N BENTON ST
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-2501
Mailing Address - Country:US
Mailing Address - Phone:573-433-2833
Mailing Address - Fax:573-433-2829
Practice Address - Street 1:119 N BENTON ST
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2501
Practice Address - Country:US
Practice Address - Phone:573-433-2833
Practice Address - Fax:573-433-2829
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist