MEDICARE: MS. THERESA ANN BOOMER MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	170300000X	Genetic Counselor (M.S.)	246.000083	IL
2	170300000X	Genetic Counselor (M.S.)	GC0000000027	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GC0000000027	OTHER	TN	LICENSED GENETIC COUNSELOR
2	246.000083	OTHER	IL	LICENSED GENETIC COUNSELOR
3	2002038	OTHER	MT	AMERICAN BOARD OF GENETIC COUNELING CERTIFICATION

General Provider Information

NPI Number	:	1205111499
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. THERESA ANN BOOMER MS

Provider Business Mailing Address
First Line	:	4 PINE RIDGE CIR
Second Line	:
City	:	CLANCY
State	:	MT
Zip	:	59634-9760
Country	:	US
Telephone Number	:	406-422-0411
Fax Number	:

Provider Business Practice Location Address
First Line	:	4 PINE RIDGE CIR
Second Line	:
City	:	CLANCY
State	:	MT
Zip	:	59634-9760
Country	:	US
Telephone Number	:	406-422-0411
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2011
Last Update Date	:	10/19/2011

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