Provider Demographics
NPI:1023077062
Name:BOELENS, DENISE MARIE (PHD)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:MARIE
Last Name:BOELENS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5801 FASHION BLVD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6159
Mailing Address - Country:US
Mailing Address - Phone:801-596-0147
Mailing Address - Fax:
Practice Address - Street 1:5801 FASHION BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6159
Practice Address - Country:US
Practice Address - Phone:801-596-0147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT110944-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5670531Medicare UPIN
UT870500469Medicare UPIN
UT743036304-01Medicare UPIN
UTS19379Medicare UPIN
UT0062940Medicare PIN