Provider Demographics
NPI:1083770101
Name:BOATMAN, TERESA A (PHD, LP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:A
Last Name:BOATMAN
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11525 40TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-1316
Mailing Address - Country:US
Mailing Address - Phone:763-234-4974
Mailing Address - Fax:
Practice Address - Street 1:11525 40TH AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-1316
Practice Address - Country:US
Practice Address - Phone:763-234-4974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4129103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN61-91292OtherUBH
MN108024OtherHEALTH PARTNERS
MN383K7BOOtherBLUE CROSS BLUE SHIELD