Provider Demographics
NPI:1447367115
Name:SUREEPISARN, BOONLERT (MHP)
Entity type:Individual
Prefix:MR
First Name:BOONLERT
Middle Name:
Last Name:SUREEPISARN
Suffix:
Gender:M
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4604 101ST PL NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-2361
Mailing Address - Country:US
Mailing Address - Phone:360-770-9876
Mailing Address - Fax:425-349-7339
Practice Address - Street 1:3322 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4425
Practice Address - Country:US
Practice Address - Phone:425-349-8188
Practice Address - Fax:425-349-7339
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00013321101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health