Healthcare Provider Details

I. General information

NPI: 1063385482
Provider Name (Legal Business Name): MRS. BRANDI SUZANNE BOYETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2025
Last Update Date: 09/24/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 ALABAMA ST
CRESTVIEW FL
32536-2544
US

IV. Provider business mailing address

5407 HIGHWAY 4
BAKER FL
32531-8435
US

V. Phone/Fax

Practice location:
  • Phone: 850-684-4651
  • Fax:
Mailing address:
  • Phone: 850-312-8680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH28423
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: