Provider Demographics
NPI:1437701026
Name:BOSS, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:BOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E 3RD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-2563
Mailing Address - Country:US
Mailing Address - Phone:541-298-2101
Mailing Address - Fax:541-298-7996
Practice Address - Street 1:401 E 3RD ST STE 101
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-2563
Practice Address - Country:US
Practice Address - Phone:541-298-2101
Practice Address - Fax:541-298-7996
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10201146106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician