Provider Demographics
NPI:1558792812
Name:BOE, BRANDON (SACIT)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BOE
Suffix:
Gender:M
Credentials:SACIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N LYNNDALE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-3056
Mailing Address - Country:US
Mailing Address - Phone:920-735-9010
Mailing Address - Fax:920-735-9050
Practice Address - Street 1:1000 N LYNNDALE DR
Practice Address - Street 2:SUITE C
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3056
Practice Address - Country:US
Practice Address - Phone:920-735-9010
Practice Address - Fax:920-735-9050
Is Sole Proprietor?:No
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16994-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)