Provider Demographics
NPI:1881806669
Name:BOUMAN, DOUGLAS A (PSYSLLP)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
Last Name:BOUMAN
Suffix:
Gender:M
Credentials:PSYSLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 PARCHMENT DRIVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3663
Mailing Address - Country:US
Mailing Address - Phone:616-957-9112
Mailing Address - Fax:616-957-2409
Practice Address - Street 1:1000 PARCHMENT DRIVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3663
Practice Address - Country:US
Practice Address - Phone:616-957-9112
Practice Address - Fax:616-957-2409
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002358103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical