Provider Demographics
NPI:1215301411
Name:BOUWMAN, MALLORY MAE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:MAE
Last Name:BOUWMAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5447 LILLY CT SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-9200
Mailing Address - Country:US
Mailing Address - Phone:616-389-2723
Mailing Address - Fax:616-454-2554
Practice Address - Street 1:385 LEONARD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1129
Practice Address - Country:US
Practice Address - Phone:616-389-2723
Practice Address - Fax:616-454-2554
Is Sole Proprietor?:No
Enumeration Date:2015-11-25
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801095229104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker