Healthcare Provider Details

I. General information

NPI: 1922933324
Provider Name (Legal Business Name): THEODORE GEORGE BOOZALIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 3080
REDLANDS CA
92373-0999
US

IV. Provider business mailing address

26258 REDLANDS BLVD APT 117
REDLANDS CA
92373-7752
US

V. Phone/Fax

Practice location:
  • Phone: 909-748-8108
  • Fax:
Mailing address:
  • Phone: 361-649-8876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: