Provider Demographics
NPI:1740369990
Name:BOOROM, PAUL J JR (MA CAGS)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:BOOROM
Suffix:JR
Gender:M
Credentials:MA CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH SMITHFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02896-7246
Mailing Address - Country:US
Mailing Address - Phone:401-762-4422
Mailing Address - Fax:
Practice Address - Street 1:18 VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:NORTH SMITHFIELD
Practice Address - State:RI
Practice Address - Zip Code:02896-7246
Practice Address - Country:US
Practice Address - Phone:401-447-2227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMHC00428101YM0800X
RIPC372101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPB61799Medicaid