Provider Demographics
NPI:1780571224
Name:HALEIGH BOUSLOG LMHC LLC
Entity type:Organization
Organization Name:HALEIGH BOUSLOG LMHC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMHC, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HALEIGH
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUSLOG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-359-1840
Mailing Address - Street 1:12345 UNIVERSITY AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8285
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12345 UNIVERSITY AVE STE 310
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8285
Practice Address - Country:US
Practice Address - Phone:515-329-0213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-18
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty