Provider Demographics
NPI:1942349451
Name:BOAKE, CORWIN (PHD)
Entity Type:Individual
Prefix:
First Name:CORWIN
Middle Name:
Last Name:BOAKE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 MOURSUND ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-3405
Mailing Address - Country:US
Mailing Address - Phone:713-799-6990
Mailing Address - Fax:713-799-7049
Practice Address - Street 1:1333 MOURSUND ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3405
Practice Address - Country:US
Practice Address - Phone:713-799-6990
Practice Address - Fax:713-799-7049
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2013-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23147103G00000X, 103TC0700X
LAMP.0661103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1625642Medicaid
TX00732TMedicare ID - Type UnspecifiedGROUP MCR
LA5DQ62Medicare PIN
TX88038HMedicare UPIN
TX1625642Medicaid