Basic Information
| Provider Information | |||||||||
| NPI: | 1275849762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSWELL | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BRUCE | ||||||||
| OtherFirstName: | BETHANY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6524 SAINT MORITZ AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752142428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143640225 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 930 W CENTERVILLE RD | ||||||||
| Address2: | |||||||||
| City: | GARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750415823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723037021 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2010 | ||||||||
| LastUpdateDate: | 12/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2355S0801X | 34989 | TX | N | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant | 235Z00000X | 107967 | TX | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 149984001 | 05 | TX | MEDICAID |