Provider Demographics
NPI:1255475612
Name:BOOHER, PENELOPE SUE WHITAKER (MA)
Entity Type:Individual
Prefix:MRS
First Name:PENELOPE
Middle Name:SUE WHITAKER
Last Name:BOOHER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 W JOHN ST
Mailing Address - Street 2:
Mailing Address - City:YORKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60560-9249
Mailing Address - Country:US
Mailing Address - Phone:630-553-9100
Mailing Address - Fax:630-553-0167
Practice Address - Street 1:811 W JOHN ST
Practice Address - Street 2:
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-9249
Practice Address - Country:US
Practice Address - Phone:630-553-9100
Practice Address - Fax:630-553-0167
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11085101YP2500X
TX2244106H00000X
IL106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional