Healthcare Provider Details

I. General information

NPI: 1104802230
Provider Name (Legal Business Name): GINA BOSCO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 OVERLAND AVE
BURLEY ID
83318-2932
US

IV. Provider business mailing address

PO BOX 462
BURLEY ID
83318-0462
US

V. Phone/Fax

Practice location:
  • Phone: 208-732-8565
  • Fax: 208-732-8566
Mailing address:
  • Phone: 208-670-3900
  • Fax: 208-732-8566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW1034
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: