Provider Demographics
NPI:1164510954
Name:BOUMAN, SANDRA D (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:D
Last Name:BOUMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 W MORELAND BLVD
Mailing Address - Street 2:SUITE #205 FAMILY SERVICE OF WAUKESHA
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188
Mailing Address - Country:US
Mailing Address - Phone:262-547-5567
Mailing Address - Fax:262-547-1608
Practice Address - Street 1:414 W MORELAND BLVD
Practice Address - Street 2:SUITE #205 FAMILY SERVICE OF WAUKESHA
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188
Practice Address - Country:US
Practice Address - Phone:262-547-5567
Practice Address - Fax:262-547-1608
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1962123104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39509400Medicaid
0000849300005Medicare ID - Type Unspecified
WI39509400Medicaid