Healthcare Provider Details

I. General information

NPI: 1447481643
Provider Name (Legal Business Name): LUCAS OWEN BOSSARD PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2009
Last Update Date: 08/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

794 EASTLAND DR
TWIN FALLS ID
83301-6856
US

IV. Provider business mailing address

794 EASTLAND DR
TWIN FALLS ID
83301-6856
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-1281
  • Fax:
Mailing address:
  • Phone: 208-734-1281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-202292
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: