Provider Demographics
NPI:1912789611
Name:BOONSTRA, MARIBETH J
Entity Type:Individual
Prefix:
First Name:MARIBETH
Middle Name:J
Last Name:BOONSTRA
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 1:691 PHEASANT RUN
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-9688
Mailing Address - Country:US
Mailing Address - Phone:630-479-6572
Mailing Address - Fax:
Practice Address - Street 1:328 N NEIL ST STE C
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3614
Practice Address - Country:US
Practice Address - Phone:217-377-0299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490252641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical