Provider Demographics
NPI:1609363985
Name:BOE, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:BOE
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 1:43 SANDY BEACH LN
Mailing Address - Street 2:
Mailing Address - City:COCOLALLA
Mailing Address - State:ID
Mailing Address - Zip Code:83813-8705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 E SELTICE WAY STE E
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7977
Practice Address - Country:US
Practice Address - Phone:208-651-9789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-22
Last Update Date:2018-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist