Healthcare Provider Details

I. General information

NPI: 1093836926
Provider Name (Legal Business Name): BRYNA ANGELIQUE BOSLEY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17940 FARMINGTON RD
LIVONIA MI
48152-4444
US

IV. Provider business mailing address

4930 HERCULES AVE APT 1
EL PASO TX
79904-3463
US

V. Phone/Fax

Practice location:
  • Phone: 734-858-0280
  • Fax: 313-388-0472
Mailing address:
  • Phone: 734-858-0278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801087976
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: