Provider Demographics
NPI:1528748241
Name:BOSTROM, ANDREW (RMHCI)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:BOSTROM
Suffix:
Gender:M
Credentials:RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 ARIANA ST APT 9
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-1957
Mailing Address - Country:US
Mailing Address - Phone:863-370-5867
Mailing Address - Fax:
Practice Address - Street 1:50 LAKE MORTON DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5343
Practice Address - Country:US
Practice Address - Phone:863-288-0821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-18
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24265101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health