Provider Demographics
NPI:1871510677
Name:BOOMGARDEN, BRIAN L (MS CADC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:BOOMGARDEN
Suffix:
Gender:M
Credentials:MS CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2290
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-2290
Mailing Address - Country:US
Mailing Address - Phone:920-320-8600
Mailing Address - Fax:920-320-8662
Practice Address - Street 1:339 REED AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-2020
Practice Address - Country:US
Practice Address - Phone:920-320-8600
Practice Address - Fax:920-320-8662
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11165101YA0400X
WI2898-123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
13647OtherNETWORK HEALTH PLAN
WI39647200Medicaid
390806395OtherCIGNA