Provider Demographics
NPI:1215987904
Name:BOSKOVITZ, MADELEINE GOTTLIEB (PHD)
Entity type:Individual
Prefix:DR
First Name:MADELEINE
Middle Name:GOTTLIEB
Last Name:BOSKOVITZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S LAKELINE BLVD APT 1518
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-2023
Mailing Address - Country:US
Mailing Address - Phone:832-496-8405
Mailing Address - Fax:713-668-6595
Practice Address - Street 1:1600 S LAKELINE BLVD APT 1518
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-2023
Practice Address - Country:US
Practice Address - Phone:832-496-8405
Practice Address - Fax:713-668-6595
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31726103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164682004Medicaid
TX164682001Medicaid
TX164682005Medicaid
TX0052PKOtherBLUE CROSS BLUE SHIELD
TX164682002Medicaid
TX164682003Medicaid
TX$$$$$$$$$OtherUNITED BEHAVIORAL HEALTH
TX8B5340Medicare ID - Type Unspecified
TX164682004Medicaid
TX164682003Medicaid
TX612863Medicare PIN
TX164682001Medicaid