Provider Demographics
NPI:1164715603
Name:BOESCH, THERESA SUSAN (BS)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:SUSAN
Last Name:BOESCH
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-2537
Mailing Address - Country:US
Mailing Address - Phone:541-482-5792
Mailing Address - Fax:
Practice Address - Street 1:1836 FREMONT ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2537
Practice Address - Country:US
Practice Address - Phone:541-482-5792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health