Provider Demographics
NPI:1952791972
Name:BOUMAN, MARY JO
Entity Type:Individual
Prefix:MS
First Name:MARY JO
Middle Name:
Last Name:BOUMAN
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 1:310 DEDHAM ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02030-2230
Mailing Address - Country:US
Mailing Address - Phone:617-512-3246
Mailing Address - Fax:
Practice Address - Street 1:310 DEDHAM ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:MA
Practice Address - Zip Code:02030-2230
Practice Address - Country:US
Practice Address - Phone:617-512-3246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3396225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist