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NPI Code Detail

MEDICARE: MARVIN LEE BOUSKA MS

MEDICARE: MARVIN LEE BOUSKA MS
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
1103TC0700XClinical Psychologist191SD

General Provider Information

NPI Number : 1730207952
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARVIN LEE BOUSKA MS
Provider Business Mailing Address
First Line : 1818 W FULTON ST
Second Line : SUITE 201
City : RAPID CITY
State : SD
Zip : 57702
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1818 W FULTON ST
Second Line : SUITE 201
City : RAPID CITY
State : SD
Zip : 57702-4377
Country : US
Telephone Number : 605-348-6500
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/26/2007
Last Update Date : 04/25/2013

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Directions to “ MARVIN LEE BOUSKA MS” Practice Location

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