Provider Demographics
NPI:1215971056
Name:BOOMGAARDEN, RENEE L (PHD)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:L
Last Name:BOOMGAARDEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 I94 BUSINESS LOOP E
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-6434
Mailing Address - Country:US
Mailing Address - Phone:701-227-7500
Mailing Address - Fax:701-227-7575
Practice Address - Street 1:1463 I94 BUSINESS LOOP E
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-6434
Practice Address - Country:US
Practice Address - Phone:701-227-7500
Practice Address - Fax:701-227-7575
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND265103T00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
680008169OtherRR MEDICARE
ND54523Medicaid
ND14293OtherBC/BS
NDN14293Medicare ID - Type Unspecified
R79560Medicare UPIN