Provider Demographics
NPI:1356235477
Name:BOERBOOM, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BOERBOOM
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 1:9 FLAGSTAFF CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-2402
Mailing Address - Country:US
Mailing Address - Phone:608-206-4912
Mailing Address - Fax:
Practice Address - Street 1:2924 MARKETPLACE DR STE 101
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53719-5334
Practice Address - Country:US
Practice Address - Phone:608-886-9595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-04
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8426-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional