Provider Demographics
NPI:1841307592
Name:HOHMAN-BULTJE, GWEN (PHD)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:HOHMAN-BULTJE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 WHEELERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50428-9167
Mailing Address - Country:US
Mailing Address - Phone:641-420-0891
Mailing Address - Fax:641-423-2893
Practice Address - Street 1:9400 WHEELERWOOD DR
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:IA
Practice Address - Zip Code:50428-9167
Practice Address - Country:US
Practice Address - Phone:641-420-0891
Practice Address - Fax:641-423-2893
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00866103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0232330Medicaid
IA04822OtherWELLMARK
IAP32568Medicare UPIN
IAI2102Medicare ID - Type Unspecified