Provider Demographics
NPI:1689204042
Name:BOERSMA, CASEY CORULLO (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:CORULLO
Last Name:BOERSMA
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12219 GOLDEN HARVEST DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9030
Mailing Address - Country:US
Mailing Address - Phone:260-467-0090
Mailing Address - Fax:
Practice Address - Street 1:12219 GOLDEN HARVEST DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-9030
Practice Address - Country:US
Practice Address - Phone:260-467-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst