Basic Information
| Provider Information | |||||||||
| NPI: | 1528489325 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSTICK | ||||||||
| FirstName: | BRITNEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 69030 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212649030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578732302 | ||||||||
| FaxNumber: | 7578732306 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 GUMWOOD DR | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234306087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573577762 | ||||||||
| FaxNumber: | 7573577765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2013 | ||||||||
| LastUpdateDate: | 04/12/2018 | ||||||||
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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 | 225100000X | 2305208079 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P01306715 | 01 | VA | MEDICARE RR PTAN | OTHER | C05954 | 01 | VA | MEDICARE GROUP PTAN | OTHER | 1528489325 | 01 | VA | MEDICAID QMB ONLY | OTHER |