Healthcare Provider Details

I. General information

NPI: 1225956436
Provider Name (Legal Business Name): BRENDAN JAMES BOATMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 EXECUTIVE PARK BLVD STE 120
WINSTON SALEM NC
27103-1534
US

IV. Provider business mailing address

250 EXECUTIVE PARK BLVD STE 120
WINSTON SALEM NC
27103-1534
US

V. Phone/Fax

Practice location:
  • Phone: 336-608-4037
  • Fax: 336-893-0569
Mailing address:
  • Phone: 336-608-4037
  • Fax: 336-893-0569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP023825
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: