Provider Demographics
NPI:1053462010
Name:BOEHNER, CONSTANCE W (HSPP)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:W
Last Name:BOEHNER
Suffix:
Gender:F
Credentials:HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 BIELBY RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47025-1055
Mailing Address - Country:US
Mailing Address - Phone:812-537-1302
Mailing Address - Fax:812-537-5219
Practice Address - Street 1:427 W EADS PKWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:IN
Practice Address - Zip Code:47025-1139
Practice Address - Country:US
Practice Address - Phone:812-537-7375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041884A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000283805OtherBLUE SHIELD
IN172150LMedicare ID - Type UnspecifiedMEDICARE