Basic Information
| Provider Information | |||||||||
| NPI: | 1376849299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSWINKLE | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMHC, CSAYC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 S WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469523867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656629971 | ||||||||
| FaxNumber: | 7656516563 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 S WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469523867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656629971 | ||||||||
| FaxNumber: | 7656516563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2011 | ||||||||
| LastUpdateDate: | 04/27/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 39002354A | IN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 100124250 | 05 | IN | MEDICAID |