Provider Demographics
NPI:1659695153
Name:BOOMER, CHARLES W
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:BOOMER
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 1:201 ALAMEDA DEL PRADO STE 103
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-6698
Mailing Address - Country:US
Mailing Address - Phone:415-457-6964
Mailing Address - Fax:
Practice Address - Street 1:201 ALAMEDA DEL PRADO
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-6688
Practice Address - Country:US
Practice Address - Phone:415-457-6964
Practice Address - Fax:415-491-0915
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)