Provider Demographics
NPI:1093230260
Name:BOELTER, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BOELTER
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 1:34923 46TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:WA
Mailing Address - Zip Code:98580-9606
Mailing Address - Country:US
Mailing Address - Phone:707-400-3241
Mailing Address - Fax:
Practice Address - Street 1:231 SE BARRINGTON DR
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-3200
Practice Address - Country:US
Practice Address - Phone:360-240-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty