Provider Demographics
NPI:1992800775
Name:BOERSMA, SIDNEY G (LCSW)
Entity type:Individual
Prefix:MR
First Name:SIDNEY
Middle Name:G
Last Name:BOERSMA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 E MCKINLEY ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-1626
Mailing Address - Country:US
Mailing Address - Phone:608-873-4859
Mailing Address - Fax:
Practice Address - Street 1:1 ROCK ISLAND ARSENAL
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61299-7530
Practice Address - Country:US
Practice Address - Phone:309-782-4910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1522271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40982300Medicare ID - Type Unspecified