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NPI Code Detail

MEDICARE: MRS. TARA JEAN BOSNIC LISW

MEDICARE: MRS. TARA JEAN BOSNIC LISW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker007613IA

General Provider Information

NPI Number : 1417258351
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. TARA JEAN BOSNIC LISW
Provider Business Mailing Address
First Line : 2300 SWAN LAKE BLVD STE 102
Second Line :
City : INDEPENDENCE
State : IA
Zip : 50644-9708
Country : US
Telephone Number : 563-579-1181
Fax Number :
Provider Business Practice Location Address
First Line : 2300 SWAN LAKE BLVD STE 102
Second Line :
City : INDEPENDENCE
State : IA
Zip : 50644-9708
Country : US
Telephone Number : 563-579-1181
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/09/2010
Last Update Date : 03/17/2018

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