Provider Demographics
NPI:1124313994
Name:BOUMA, THERESA S (LCPC)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:S
Last Name:BOUMA
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 OLD SOLOMONS ISLAND RD
Mailing Address - Street 2:U7
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3845
Mailing Address - Country:US
Mailing Address - Phone:410-266-8345
Mailing Address - Fax:410-266-6278
Practice Address - Street 1:108 OLD SOLOMONS ISLAND RD
Practice Address - Street 2:U7
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3845
Practice Address - Country:US
Practice Address - Phone:410-266-8345
Practice Address - Fax:410-266-6278
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2547101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional