Provider Demographics
NPI:1558190074
Name:BOODRAM, KATLYN ALIANA
Entity type:Individual
Prefix:
First Name:KATLYN
Middle Name:ALIANA
Last Name:BOODRAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 ISABELLA DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-1719
Mailing Address - Country:US
Mailing Address - Phone:321-381-8545
Mailing Address - Fax:
Practice Address - Street 1:3880 CATALINA ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2211
Practice Address - Country:US
Practice Address - Phone:786-499-4694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRBT-24-363962106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL123459500Medicaid