Provider Demographics
NPI:1346953783
Name:BOETTCHER, TAYLOR MARIE
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MARIE
Last Name:BOETTCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47785 COUNTY ROAD 15
Mailing Address - Street 2:
Mailing Address - City:NICOLLET
Mailing Address - State:MN
Mailing Address - Zip Code:56074-4216
Mailing Address - Country:US
Mailing Address - Phone:507-262-0909
Mailing Address - Fax:
Practice Address - Street 1:1720 BASSETT DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6569
Practice Address - Country:US
Practice Address - Phone:507-522-5789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-30
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician