Provider Demographics
NPI:1245706274
Name:BOCANEGRA, JOEL (PHD)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:BOCANEGRA
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 1:5740 ARROWHEAD DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-4659
Mailing Address - Country:US
Mailing Address - Phone:502-689-3428
Mailing Address - Fax:
Practice Address - Street 1:357 W CENTER ST STE 3
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-3236
Practice Address - Country:US
Practice Address - Phone:208-244-0081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2024-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-203077103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist