Healthcare Provider Details

I. General information

NPI: 1124486907
Provider Name (Legal Business Name): JOSIE BOGGS LSWA-IC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2016
Last Update Date: 02/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2273 S VISTA AVE STE 190
BOISE ID
83705-7341
US

IV. Provider business mailing address

11802 W JENILYN CT
BOISE ID
83713-1794
US

V. Phone/Fax

Practice location:
  • Phone: 208-343-2737
  • Fax:
Mailing address:
  • Phone: 801-633-5918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSC60331369
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: