Basic Information
Provider Information | |||||||||
NPI: | 1871510677 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOOMGARDEN | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS CADC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2290 | ||||||||
Address2: |   | ||||||||
City: | MANITOWOC | ||||||||
State: | WI | ||||||||
PostalCode: | 542212290 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9203208600 | ||||||||
FaxNumber: | 9203208662 | ||||||||
Practice Location | |||||||||
Address1: | 339 REED AVE | ||||||||
Address2: |   | ||||||||
City: | MANITOWOC | ||||||||
State: | WI | ||||||||
PostalCode: | 542202020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9203208600 | ||||||||
FaxNumber: | 9203208662 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2006 | ||||||||
LastUpdateDate: | 06/03/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 11165 | WI | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 2898-123 | WI | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 13647 | 01 |   | NETWORK HEALTH PLAN | OTHER | 39647200 | 05 | WI |   | MEDICAID | 390806395 | 01 |   | CIGNA | OTHER |