Provider Demographics
NPI:1245231257
Name:BOUWMA, JOAN R (SW)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:R
Last Name:BOUWMA
Suffix:
Gender:F
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 OAK AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-2407
Mailing Address - Country:US
Mailing Address - Phone:231-767-9806
Mailing Address - Fax:231-767-9840
Practice Address - Street 1:1700 OAK AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-2407
Practice Address - Country:US
Practice Address - Phone:231-767-9806
Practice Address - Fax:231-767-9840
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010754681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q38373Medicare UPIN