Provider Demographics
NPI:1013755677
Name:BOUMA, WENDI
Entity type:Individual
Prefix:
First Name:WENDI
Middle Name:
Last Name:BOUMA
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 1:536 LOWER BIG SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-8748
Mailing Address - Country:US
Mailing Address - Phone:706-594-0172
Mailing Address - Fax:
Practice Address - Street 1:536 LOWER BIG SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-8748
Practice Address - Country:US
Practice Address - Phone:706-594-0172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician