Provider Demographics
NPI:1376849299
Name:BOSWINKLE, BRETT ALLEN (LMHC, CSAYC)
Entity type:Individual
Prefix:MR
First Name:BRETT
Middle Name:ALLEN
Last Name:BOSWINKLE
Suffix:
Gender:M
Credentials:LMHC, CSAYC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-3867
Mailing Address - Country:US
Mailing Address - Phone:765-662-9971
Mailing Address - Fax:765-651-6563
Practice Address - Street 1:101 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-3867
Practice Address - Country:US
Practice Address - Phone:765-662-9971
Practice Address - Fax:765-651-6563
Is Sole Proprietor?:No
Enumeration Date:2011-02-10
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002354A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100124250Medicaid