Provider Demographics
NPI:1205111499
Name:BOOMER, THERESA ANN (MS)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ANN
Last Name:BOOMER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:THERESA
Other - Middle Name:ANN
Other - Last Name:HOPKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4 PINE RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:CLANCY
Mailing Address - State:MT
Mailing Address - Zip Code:59634-9760
Mailing Address - Country:US
Mailing Address - Phone:406-422-0411
Mailing Address - Fax:
Practice Address - Street 1:4 PINE RIDGE CIR
Practice Address - Street 2:
Practice Address - City:CLANCY
Practice Address - State:MT
Practice Address - Zip Code:59634-9760
Practice Address - Country:US
Practice Address - Phone:406-422-0411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL246.000083170300000X
TNGC0000000027170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNGC0000000027OtherLICENSED GENETIC COUNSELOR
IL246.000083OtherLICENSED GENETIC COUNSELOR
MT2002038OtherAMERICAN BOARD OF GENETIC COUNELING CERTIFICATION