Provider Demographics
NPI:1922819531
Name:BOUWMAN, LIESJE CHANTAL (LMSW)
Entity type:Individual
Prefix:
First Name:LIESJE
Middle Name:CHANTAL
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 1:5375 N 3000 W
Mailing Address - Street 2:
Mailing Address - City:TETONIA
Mailing Address - State:ID
Mailing Address - Zip Code:83452-1201
Mailing Address - Country:US
Mailing Address - Phone:208-527-6566
Mailing Address - Fax:
Practice Address - Street 1:89 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5141
Practice Address - Country:US
Practice Address - Phone:307-734-6040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8921896104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker