Basic Information
| Provider Information | |||||||||
| NPI: | 1992193619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSWELL | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | M.ED, BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1451 RIVER PARK DR STE 285 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958154522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772646747 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 495 SEAPORT CT STE 102 | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940632785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772646747 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2015 | ||||||||
| LastUpdateDate: | 02/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1149751 | GA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.