Provider Demographics
NPI:1124614375
Name:BEAUCHEMIN-BOGGIO, LORI JUN
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:JUN
Last Name:BEAUCHEMIN-BOGGIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15811 LAKE BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:LYTLE
Mailing Address - State:TX
Mailing Address - Zip Code:78052-4560
Mailing Address - Country:US
Mailing Address - Phone:210-748-2265
Mailing Address - Fax:
Practice Address - Street 1:15811 LAKE BREEZE DR
Practice Address - Street 2:
Practice Address - City:LYTLE
Practice Address - State:TX
Practice Address - Zip Code:78052-4560
Practice Address - Country:US
Practice Address - Phone:210-748-2265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX598491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical