Provider Demographics
NPI:1083090658
Name:BOULWARE, KATHERINE (MS)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1884 RICHARDS PL
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-9266
Mailing Address - Country:US
Mailing Address - Phone:626-506-6265
Mailing Address - Fax:
Practice Address - Street 1:1 N INDIAN HILL BLVD STE 208
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4769
Practice Address - Country:US
Practice Address - Phone:747-218-1622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6641101YA0400X
CA120535106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)