Provider Demographics
NPI:1528955622
Name:BOAZEMAN, DONIQUE
Entity type:Individual
Prefix:
First Name:DONIQUE
Middle Name:
Last Name:BOAZEMAN
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 1:225 MAIN ST UNIT 202
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-6101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3140 JUANIPERO WAY STE 101
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8647
Practice Address - Country:US
Practice Address - Phone:541-323-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-20
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171400000XOther Service ProvidersHealth & Wellness Coach
No172V00000XOther Service ProvidersCommunity Health Worker
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health