Provider Demographics
NPI:1417510249
Name:BOERSEN, MICHAEL (BA, HAD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BOERSEN
Suffix:
Gender:M
Credentials:BA, HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 E FERN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4000
Mailing Address - Country:US
Mailing Address - Phone:909-792-0074
Mailing Address - Fax:
Practice Address - Street 1:16 E FERN AVE STE C
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4000
Practice Address - Country:US
Practice Address - Phone:909-792-0074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA8045237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14549148OtherCAQH