Basic Information
| Provider Information | |||||||||
| NPI: | 1093230260 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOELTER | ||||||||
| FirstName: | BRANDON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34923 46TH AVE S | ||||||||
| Address2: | |||||||||
| City: | ROY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985809606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074003241 | ||||||||
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| Practice Location | |||||||||
| Address1: | 231 SE BARRINGTON DR | ||||||||
| Address2: | |||||||||
| City: | OAK HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982773200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602400022 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2017 | ||||||||
| LastUpdateDate: | 08/09/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.