Healthcare Provider Details

I. General information

NPI: 1548203730
Provider Name (Legal Business Name): BOSWORTH THERAPY & CONSULTATION SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 JACKSON BLVD
RAPID CITY SD
57702
US

IV. Provider business mailing address

3213 WEST MAIN STREET # 215
RAPID CITY SD
57702
US

V. Phone/Fax

Practice location:
  • Phone: 605-343-7755
  • Fax: 605-721-8896
Mailing address:
  • Phone: 605-343-7755
  • Fax: 605-721-8896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1590
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6570593
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name: MR. THOMAS MATTHEW BOSWORTH
Title or Position: PRESIDENT
Credential:
Phone: 605-343-7755