Provider Demographics
NPI:1053735415
Name:SHEHAN-BOOGAARD, MARY LEONETTE (TLLP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:LEONETTE
Last Name:SHEHAN-BOOGAARD
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 E JOLLY RD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-6818
Mailing Address - Country:US
Mailing Address - Phone:517-346-9501
Mailing Address - Fax:517-346-8170
Practice Address - Street 1:812 E JOLLY RD
Practice Address - Street 2:SUITE 114
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-6818
Practice Address - Country:US
Practice Address - Phone:517-346-9501
Practice Address - Fax:517-346-8170
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014515103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist