Provider Demographics
NPI:1316353253
Name:BOEREMA, TIMOTHY (LISW)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:BOEREMA
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 DUBLIN RD
Mailing Address - Street 2:212C
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1000
Mailing Address - Country:US
Mailing Address - Phone:614-437-9910
Mailing Address - Fax:614-453-5975
Practice Address - Street 1:1335 DUBLIN RD
Practice Address - Street 2:212C
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1000
Practice Address - Country:US
Practice Address - Phone:614-437-9910
Practice Address - Fax:614-453-5975
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-10
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.07000751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical