Healthcare Provider Details

I. General information

NPI: 1164624771
Provider Name (Legal Business Name): THERESA ANN BOYLE LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E BROAD ST
HAZLETON PA
18201-6835
US

IV. Provider business mailing address

40 SUNBURST DR
HAZLETON PA
18202-9483
US

V. Phone/Fax

Practice location:
  • Phone: 570-455-6385
  • Fax:
Mailing address:
  • Phone: 570-455-7526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW0003185E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: