Provider Demographics
NPI:1184414914
Name:BOSMA, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:BOSMA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2568 104TH AVE
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-6801
Mailing Address - Country:US
Mailing Address - Phone:616-430-4166
Mailing Address - Fax:
Practice Address - Street 1:238 HOOVER BLVD STE 30
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3782
Practice Address - Country:US
Practice Address - Phone:616-312-2989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-06
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851119795104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker