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NPI Code Detail

MEDICARE: LAURIE ANN BOUSSOM LMSW

MEDICARE: LAURIE ANN BOUSSOM LMSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1104100000XSocial Worker6801077021MI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1447342563
Entity Type Code : Individual
Provider Name (Legal Business Name) : LAURIE ANN BOUSSOM LMSW
Provider Business Mailing Address
First Line : 304 HALL ST
Second Line :
City : BELDING
State : MI
Zip : 48809-1722
Country : US
Telephone Number : 616-902-4760
Fax Number :
Provider Business Practice Location Address
First Line : 375 APPLE TREE DR
Second Line :
City : IONIA
State : MI
Zip : 48846-7506
Country : US
Telephone Number : 616-902-4760
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/28/2006
Last Update Date : 12/18/2010

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Directions to “ LAURIE ANN BOUSSOM LMSW” Practice Location

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