Provider Demographics
NPI:1275781643
Name:BOULWARE, CAROL DIANE (LMT)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:DIANE
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2060
Mailing Address - Country:US
Mailing Address - Phone:217-242-3495
Mailing Address - Fax:
Practice Address - Street 1:1615 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2060
Practice Address - Country:US
Practice Address - Phone:217-242-3495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005038798225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist