Provider Demographics
NPI:1730533696
Name:BOOMER, TEARA S
Entity type:Individual
Prefix:
First Name:TEARA
Middle Name:S
Last Name:BOOMER
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 1:8974 162ND ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-5011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8974 162ND ST
Practice Address - Street 2:5 FL
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5011
Practice Address - Country:US
Practice Address - Phone:718-206-3440
Practice Address - Fax:718-206-3638
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker