Provider Demographics
NPI:1366064990
Name:BOISVERT, DANIELLE LAUREN (PHD)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:LAUREN
Last Name:BOISVERT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 CAPTAIN JOHN JACOBS RD APT 107
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-5370
Mailing Address - Country:US
Mailing Address - Phone:203-215-3840
Mailing Address - Fax:
Practice Address - Street 1:20 N WACKER DR STE 1442
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-2906
Practice Address - Country:US
Practice Address - Phone:312-372-4731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMFT000233106H00000X
MA1847-MH-MF106H00000X
IL166.001376106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist