Provider Demographics
NPI:1235335290
Name:BOERMA, BRIAN JAMES (MA)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JAMES
Last Name:BOERMA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814-1340
Mailing Address - Country:US
Mailing Address - Phone:541-523-7400
Mailing Address - Fax:541-523-4927
Practice Address - Street 1:3425 13TH ST
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-1340
Practice Address - Country:US
Practice Address - Phone:541-523-7400
Practice Address - Fax:541-523-4927
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010452101YP2500X
ORC5728101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500794921Medicaid
ORB176375OtherODL