Provider Demographics
NPI:1225392731
Name:BOUMAN, SAM H (PHD, LEP)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:H
Last Name:BOUMAN
Suffix:
Gender:M
Credentials:PHD, LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1069 W 22ND ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-1283
Mailing Address - Country:US
Mailing Address - Phone:909-896-8133
Mailing Address - Fax:
Practice Address - Street 1:1069 W 22ND ST
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91784-1283
Practice Address - Country:US
Practice Address - Phone:909-896-8133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2654103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool