Provider Demographics
NPI:1154320596
Name:BOOHER, JOSHUA DAVID (PHD)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:DAVID
Last Name:BOOHER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPARTMENT 888182
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37995-0001
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:501 ADESSA PKWY
Practice Address - Street 2:STE A-150
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37771-6725
Practice Address - Country:US
Practice Address - Phone:865-986-8082
Practice Address - Fax:865-986-5890
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP2549103TS0200X
TN2549 (PROVISIONAL)103TS0200X
TN103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3981432Medicaid
TN3981432Medicare ID - Type Unspecified