MEDICARE: BRIAN KEITH BOELK MSW

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
1	104100000X	Social Worker
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1093330839
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN KEITH BOELK MSW

Provider Business Mailing Address
First Line	:	1098 FOREST LAKE TER
Second Line	:
City	:	NICEVILLE
State	:	FL
Zip	:	32578-2137
Country	:	US
Telephone Number	:	707-803-1368
Fax Number	:

Provider Business Practice Location Address
First Line	:	531 EGLIN PKWY NE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-2829
Country	:	US
Telephone Number	:	850-396-1217
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2020
Last Update Date	:	06/08/2020

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