Individual
DR. MANIJEH BOUSTANI
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PH.D.
Contact information
Practice address
2401 WOOTEN BLVD SW STE K, WILSON, NC 27893-4464
(252) 291-0735
(252) 291-2890
Mailing address
608 PENNCROSS DR, RALEIGH, NC 27610-2177
(919) 656-3589
(919) 243-0923
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
1456
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0416L
BLUE CROSS BLUE SHIELD
NC
05
—
6000563
—
NC
05
—
6000721
—
NC
Enumeration date
10/05/2006
Last updated
09/20/2018
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