Provider Demographics
NPI:1962905596
Name:BOOMS, ETHAN JOSEPH (OTRL)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:JOSEPH
Last Name:BOOMS
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 IRVING AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-5375
Mailing Address - Country:US
Mailing Address - Phone:989-583-6387
Mailing Address - Fax:
Practice Address - Street 1:1447 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4727
Practice Address - Country:US
Practice Address - Phone:989-583-6387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009403225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist