Basic Information
| Provider Information | |||||||||
| NPI: | 1912297409 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOESE | ||||||||
| FirstName: | ROSHAN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA CCC SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOESE | ||||||||
| OtherFirstName: | ROSHAN | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MA CCC SLP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 492 GRAY HORSE CIR | ||||||||
| Address2: | |||||||||
| City: | WOODLAND PARK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808638943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057592843 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1330 QUAIL LAKE LOOP STE 200 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809064651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195402108 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2011 | ||||||||
| LastUpdateDate: | 08/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 1451 | NE | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SLP.0001917 | CO | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.