Provider Demographics
NPI:1699044693
Name:BOUMA, CHARLENE KAY (PTA)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:KAY
Last Name:BOUMA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 S DAKOTA ST
Mailing Address - Street 2:
Mailing Address - City:CONRAD
Mailing Address - State:MT
Mailing Address - Zip Code:59425-2414
Mailing Address - Country:US
Mailing Address - Phone:406-278-7139
Mailing Address - Fax:
Practice Address - Street 1:805 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:CONRAD
Practice Address - State:MT
Practice Address - Zip Code:59425-1717
Practice Address - Country:US
Practice Address - Phone:406-271-2295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1581172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker