Provider Demographics
NPI:1417090812
Name:BOETTCHER, S. BRUCE (LMFT)
Entity Type:Individual
Prefix:
First Name:S.
Middle Name:BRUCE
Last Name:BOETTCHER
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2498 CONCORD AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:UT
Mailing Address - Zip Code:84765-5621
Mailing Address - Country:US
Mailing Address - Phone:435-628-0624
Mailing Address - Fax:435-674-9380
Practice Address - Street 1:437 S BLUFF ST STE 202
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3555
Practice Address - Country:US
Practice Address - Phone:435-628-0624
Practice Address - Fax:435-674-9380
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT319524-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist