Provider Demographics
NPI:1922349745
Name:BOETTCHER, TERA (MSW)
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:
Last Name:BOETTCHER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 HAMILTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1525
Mailing Address - Country:US
Mailing Address - Phone:309-637-1695
Mailing Address - Fax:306-589-7981
Practice Address - Street 1:1200 HAMILTON BLVD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1525
Practice Address - Country:US
Practice Address - Phone:309-637-1695
Practice Address - Fax:306-589-7981
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149015105101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health