Provider Demographics
NPI:1891091393
Name:FLANNERY BORIS, MYSTICA ROSE (BCABA)
Entity type:Individual
Prefix:MS
First Name:MYSTICA
Middle Name:ROSE
Last Name:FLANNERY BORIS
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:MYSTICA
Other - Middle Name:ROSE
Other - Last Name:FLANNERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:633 EAST MAIN ST UNIT A5
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057
Mailing Address - Country:US
Mailing Address - Phone:609-506-7728
Mailing Address - Fax:
Practice Address - Street 1:633 EAST MAIN ST UNIT A5
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057
Practice Address - Country:US
Practice Address - Phone:609-506-7728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst