Healthcare Provider Details

I. General information

NPI: 1679314520
Provider Name (Legal Business Name): MARKUS BOSLEY PSS, PAS-DOT, LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

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

500 N 21ST ST
MONROE LA
71201-6532
US

IV. Provider business mailing address

1108 STUBBS AVE
MONROE LA
71201-5620
US

V. Phone/Fax

Practice location:
  • Phone: 318-791-9805
  • Fax: 318-855-4396
Mailing address:
  • Phone: 318-791-9805
  • Fax: 318-855-4396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLAC-5143
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: