Provider Demographics
NPI:1295964518
Name:BOOMGAARDEN, LARRY W (BA, LAC-T)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:W
Last Name:BOOMGAARDEN
Suffix:
Gender:M
Credentials:BA, LAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 8TH ST SE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-2819
Mailing Address - Country:US
Mailing Address - Phone:218-847-0696
Mailing Address - Fax:218-847-4198
Practice Address - Street 1:1000 8TH ST SE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-2819
Practice Address - Country:US
Practice Address - Phone:218-847-0696
Practice Address - Fax:218-847-4198
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)