Provider Demographics
NPI:1578139937
Name:BOYUM, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:BOYUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:HANKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58041-0100
Mailing Address - Country:US
Mailing Address - Phone:701-242-7031
Mailing Address - Fax:
Practice Address - Street 1:102 6TH ST SE
Practice Address - Street 2:
Practice Address - City:HANKINSON
Practice Address - State:ND
Practice Address - Zip Code:58041-4200
Practice Address - Country:US
Practice Address - Phone:701-242-7031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1951235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist