Provider Demographics
NPI:1679629034
Name:BOOMER, LOIS (OT)
Entity type:Individual
Prefix:
First Name:LOIS
Middle Name:
Last Name:BOOMER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:NATURITA
Mailing Address - State:CO
Mailing Address - Zip Code:81422-0102
Mailing Address - Country:US
Mailing Address - Phone:970-765-4533
Mailing Address - Fax:
Practice Address - Street 1:336 S 10TH ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4934
Practice Address - Country:US
Practice Address - Phone:970-249-1412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT105065-4201225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT999000021033 D1240Medicaid