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NPI Code Detail

MEDICARE: DOUGLAS BOOSE

MEDICARE: DOUGLAS BOOSE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YA0400XAddiction (Substance Use Disorder) CounselorLICDC.161467OH
2101YA0400XAddiction (Substance Use Disorder) CounselorC.1801578OH

General Provider Information

NPI Number : 1609381912
Entity Type Code : Individual
Provider Name (Legal Business Name) : DOUGLAS BOOSE
Provider Business Mailing Address
First Line : 20800 WESTGATE PROFESSIONAL CENTER
Second Line : SUITE 200
City : FAIRVIEW PARK
State : OH
Zip : 44126
Country : US
Telephone Number : 440-333-4949
Fax Number : 440-333-5044
Provider Business Practice Location Address
First Line : 23412 COMMERCE PARK
Second Line :
City : BEACHWOOD
State : OH
Zip : 44122-5813
Country : US
Telephone Number : 216-400-6640
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/08/2017
Last Update Date : 02/25/2025

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