Provider Demographics
NPI:1194872275
Name:BOUGHMAN, ARVIS BENNETT (MACCCSLP)
Entity type:Individual
Prefix:MR
First Name:ARVIS
Middle Name:BENNETT
Last Name:BOUGHMAN
Suffix:
Gender:M
Credentials:MACCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2795
Mailing Address - Street 2:202 MIMOSA DRIVE
Mailing Address - City:DREXEL
Mailing Address - State:NC
Mailing Address - Zip Code:28619-2795
Mailing Address - Country:US
Mailing Address - Phone:828-443-4395
Mailing Address - Fax:
Practice Address - Street 1:202 MIMOSA DRIVE
Practice Address - Street 2:
Practice Address - City:DREXEL
Practice Address - State:NC
Practice Address - Zip Code:28619-2795
Practice Address - Country:US
Practice Address - Phone:828-443-4395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCSLP 4704235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411307Medicaid