Healthcare Provider Details

I. General information

NPI: 1679031496
Provider Name (Legal Business Name): JUDY LORAINE BOERS LEP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 50TH ST
SACRAMENTO CA
95819-2215
US

IV. Provider business mailing address

60 50TH ST
SACRAMENTO CA
95819-2215
US

V. Phone/Fax

Practice location:
  • Phone: 916-296-4211
  • Fax:
Mailing address:
  • Phone: 916-296-4211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number2412
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: