Provider Demographics
NPI:1730963232
Name:BOULDIN, JOHN ROBERT III
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ROBERT
Last Name:BOULDIN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 W NASHVILLE DR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27856-1284
Mailing Address - Country:US
Mailing Address - Phone:252-904-2131
Mailing Address - Fax:
Practice Address - Street 1:115 W NASHVILLE DR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:NC
Practice Address - Zip Code:27856-1284
Practice Address - Country:US
Practice Address - Phone:252-904-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-23-279907106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician