Provider Demographics
NPI:1730207952
Name:BOUSKA, MARVIN LEE (MS)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:LEE
Last Name:BOUSKA
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 W FULTON ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1818 W FULTON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-4377
Practice Address - Country:US
Practice Address - Phone:605-348-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD191103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical