Provider Demographics
NPI:1528299492
Name:BOUGHTON, BEVERLY
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:BOUGHTON
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 1:711 SULLIVAN ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-2322
Mailing Address - Country:US
Mailing Address - Phone:607-737-6151
Mailing Address - Fax:607-734-2943
Practice Address - Street 1:711 SULLIVAN ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-2322
Practice Address - Country:US
Practice Address - Phone:607-737-6151
Practice Address - Fax:607-734-2943
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY72079206104100000X
NY083145-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker