Provider Demographics
NPI:1699174185
Name:BOOSE, TERESA C (LCSW)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:C
Last Name:BOOSE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 STACEY BURK DR
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:IL
Mailing Address - Zip Code:62839-3241
Mailing Address - Country:US
Mailing Address - Phone:618-662-2191
Mailing Address - Fax:618-662-8090
Practice Address - Street 1:929 STACEY BURK DR
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-3241
Practice Address - Country:US
Practice Address - Phone:618-662-2191
Practice Address - Fax:618-662-8090
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0099311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical