Provider Demographics
NPI:1881266856
Name:SAMUEL BOKO, THERESA MICHAEL
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MICHAEL
Last Name:SAMUEL BOKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1994 MURGUIA AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-6957
Mailing Address - Country:US
Mailing Address - Phone:408-712-0009
Mailing Address - Fax:
Practice Address - Street 1:251 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-1940
Practice Address - Country:US
Practice Address - Phone:408-379-3790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-10
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor