1205111499 NPI number — MS. THERESA ANN BOOMER MS

Table of content: MS. THERESA ANN BOOMER MS (NPI 1205111499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205111499 NPI number — MS. THERESA ANN BOOMER MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOOMER
Provider First Name:
THERESA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOPKINS
Provider Other First Name:
THERESA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205111499
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 PINE RIDGE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLANCY
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59634-9760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-422-0411
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 PINE RIDGE CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLANCY
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59634-9760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-422-0411
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 170300000X , with the licence number:  246.000083 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 170300000X , with the licence number: GC0000000027 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GC0000000027 . This is a "LICENSED GENETIC COUNSELOR" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 246.000083 . This is a "LICENSED GENETIC COUNSELOR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 2002038 . This is a "AMERICAN BOARD OF GENETIC COUNELING CERTIFICATION" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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