MEDICARE: DESSIRAE BOULWARE PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY28641	CA
2	103TC0700X	Clinical Psychologist	38405	TX

General Provider Information

NPI Number	:	1376827519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESSIRAE BOULWARE PSYD

Provider Business Mailing Address
First Line	:	PO BOX 66211
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77266-6211
Country	:	US
Telephone Number	:	281-728-0766
Fax Number	:

Provider Business Practice Location Address
First Line	:	3833 DUNLAVY STREET
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77006-4769
Country	:	US
Telephone Number	:	281-728-0766
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2011
Last Update Date	:	10/01/2020

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