Healthcare Provider Details

I. General information

NPI: 1700211075
Provider Name (Legal Business Name): THELMA BEATRICA BOAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 N BOSTON AVE
TULSA OK
74106-4604
US

IV. Provider business mailing address

1014 E 66TH PL APT 527
TULSA OK
74136-3717
US

V. Phone/Fax

Practice location:
  • Phone: 918-855-0761
  • Fax:
Mailing address:
  • Phone: 918-855-0761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: