Provider Demographics
NPI:1720602972
Name:BOEN, THERESA LOREEN (EDS)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LOREEN
Last Name:BOEN
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 W ROAD 1 N
Mailing Address - Street 2:
Mailing Address - City:CHINO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86323-6062
Mailing Address - Country:US
Mailing Address - Phone:303-918-9913
Mailing Address - Fax:
Practice Address - Street 1:1925 W ROAD 1 N
Practice Address - Street 2:
Practice Address - City:CHINO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86323-6062
Practice Address - Country:US
Practice Address - Phone:303-918-9913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA210174284103TS0200X
CO376693103TS0200X
AZ7375736103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool