Provider Demographics
NPI:1023382827
Name:BOU-MATAR, TERESA T (LPC)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:T
Last Name:BOU-MATAR
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 25 1/2 ROAD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505
Mailing Address - Country:US
Mailing Address - Phone:970-260-7017
Mailing Address - Fax:
Practice Address - Street 1:677 25 1/2 RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-6956
Practice Address - Country:US
Practice Address - Phone:970-260-7017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1621101YP2500X
CO0401540101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool