Healthcare Provider Details

I. General information

NPI: 1356182208
Provider Name (Legal Business Name): BOSLEY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 STUBBS AVE
MONROE LA
71201-5620
US

IV. Provider business mailing address

1108 STUBBS AVE
MONROE LA
71201-5620
US

V. Phone/Fax

Practice location:
  • Phone: 318-791-9805
  • Fax:
Mailing address:
  • Phone: 318-791-9805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARKUS REVIELLE BOSLEY
Title or Position: ADMINISTRATOR
Credential: PSS, PAS-DOT, LAC
Phone: 318-791-9805