Provider Demographics
NPI:1598541914
Name:BOEMBEKE, BRICE REMI
Entity Type:Individual
Prefix:
First Name:BRICE
Middle Name:REMI
Last Name:BOEMBEKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4369 S HOWELL AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-5055
Mailing Address - Country:US
Mailing Address - Phone:414-999-0102
Mailing Address - Fax:
Practice Address - Street 1:4369 S HOWELL AVE STE 306
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-5055
Practice Address - Country:US
Practice Address - Phone:414-999-0102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7593-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health