Provider Demographics
NPI:1174001556
Name:BOUSMAN, MARIBETH (BA, CADC)
Entity Type:Individual
Prefix:
First Name:MARIBETH
Middle Name:
Last Name:BOUSMAN
Suffix:
Gender:F
Credentials:BA, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-2429
Mailing Address - Country:US
Mailing Address - Phone:563-242-6805
Mailing Address - Fax:563-242-2011
Practice Address - Street 1:2219 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-2429
Practice Address - Country:US
Practice Address - Phone:563-242-6805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18021101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)