Healthcare Provider Details

I. General information

NPI: 1942349451
Provider Name (Legal Business Name): CORWIN BOAKE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 03/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 MOURSUND ST
HOUSTON TX
77030-3405
US

IV. Provider business mailing address

1333 MOURSUND ST
HOUSTON TX
77030-3405
US

V. Phone/Fax

Practice location:
  • Phone: 713-799-6990
  • Fax: 713-799-7049
Mailing address:
  • Phone: 713-799-6990
  • Fax: 713-799-7049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number23147
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number23147
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License NumberMP.0661
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: