Basic Information
| Provider Information | |||||||||
| NPI: | 1154320596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOOHER | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPARTMENT 888182 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003553565 | ||||||||
| FaxNumber: | 4237142355 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 ADESSA PKWY | ||||||||
| Address2: | STE A-150 | ||||||||
| City: | LENOIR CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377716725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659868082 | ||||||||
| FaxNumber: | 8659865890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 07/26/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | P2549 | TN | N | Behavioral Health & Social Service Providers | Psychologist | School | 103TS0200X | 2549 (PROVISIONAL) | TN | Y | Behavioral Health & Social Service Providers | Psychologist | School | 103TS0200X | TN | N | Behavioral Health & Social Service Providers | Psychologist | School |
ID Information
| ID | Type | State | Issuer | Description | 3981432 | 05 | TN | MEDICAID |