Basic Information
| Provider Information | |||||||||
| NPI: | 1376749598 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSWELL | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 HOWE AVE | ||||||||
| Address2: | SUITE 440 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958251073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165698484 | ||||||||
| FaxNumber: | 9165505003 | ||||||||
| Practice Location | |||||||||
| Address1: | 1908 N BEALE RD | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959016937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307436888 | ||||||||
| FaxNumber: | 5307439823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 05/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 7261 123 | WI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 76405 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 40967800 | 05 | WI | MEDICAID |