Healthcare Provider Details

I. General information

NPI: 1073196127
Provider Name (Legal Business Name): ELLEN BOSMAN MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 S TELSHOR BLVD STE Q102
LAS CRUCES NM
88011-4681
US

IV. Provider business mailing address

2058 CORTABELLA
LAS CRUCES NM
88005-8234
US

V. Phone/Fax

Practice location:
  • Phone: 575-635-5379
  • Fax:
Mailing address:
  • Phone: 575-635-5379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: