Provider Demographics
NPI:1538693114
Name:BOUMAN, TIM (LPC)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:BOUMAN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11111 HOUZE RD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-5663
Mailing Address - Country:US
Mailing Address - Phone:404-271-9009
Mailing Address - Fax:
Practice Address - Street 1:11111 HOUZE RD
Practice Address - Street 2:SUITE 320
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5663
Practice Address - Country:US
Practice Address - Phone:404-271-9009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2991101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional