Provider Demographics
NPI:1134215031
Name:BOUSTANI, MANIJEH (PHD)
Entity type:Individual
Prefix:DR
First Name:MANIJEH
Middle Name:
Last Name:BOUSTANI
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 1:608 PENNCROSS DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-2177
Mailing Address - Country:US
Mailing Address - Phone:919-656-3589
Mailing Address - Fax:919-243-0923
Practice Address - Street 1:2401 WOOTEN BLVD SW STE K
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4464
Practice Address - Country:US
Practice Address - Phone:252-291-0735
Practice Address - Fax:252-291-2890
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1456103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000721Medicaid
NC6000563Medicaid
NC0416LOtherBLUE CROSS BLUE SHIELD
NC0416LOtherBLUE CROSS BLUE SHIELD