Provider Demographics
NPI:1376827519
Name:BOULWARE, DESSIRAE (PSYD)
Entity Type:Individual
Prefix:
First Name:DESSIRAE
Middle Name:
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 66211
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77266-6211
Mailing Address - Country:US
Mailing Address - Phone:281-728-0766
Mailing Address - Fax:
Practice Address - Street 1:3833 DUNLAVY STREET
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77006-4769
Practice Address - Country:US
Practice Address - Phone:281-728-0766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28641103TC0700X
TX38405103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical