Healthcare Provider Details

I. General information

NPI: 1235137050
Provider Name (Legal Business Name): SHARMISTHA BOSE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 FOXFIELD RD STE 202
ST CHARLES IL
60174-1402
US

IV. Provider business mailing address

2075 FOXFIELD RD STE 202
ST CHARLES IL
60174-1402
US

V. Phone/Fax

Practice location:
  • Phone: 630-377-3535
  • Fax: 630-377-6703
Mailing address:
  • Phone: 630-377-3535
  • Fax: 630-377-6703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071005939
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: