Provider Demographics
NPI:1073124632
Name:FOREMAN, BRIAN CAMERON
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CAMERON
Last Name:FOREMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 TRIUMPH DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-5928
Mailing Address - Country:US
Mailing Address - Phone:208-412-4305
Mailing Address - Fax:
Practice Address - Street 1:1200 TRIUMPH DR
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:ID
Practice Address - Zip Code:83644-5928
Practice Address - Country:US
Practice Address - Phone:298-412-4395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician