Healthcare Provider Details

I. General information

NPI: 1922202530
Provider Name (Legal Business Name): SUSAN ELIZABETH BOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8005 CORNERWOOD DR
AUSTIN TX
78717-4927
US

IV. Provider business mailing address

8507 CHAT LN
ROUND ROCK TX
78681-3683
US

V. Phone/Fax

Practice location:
  • Phone: 512-716-1890
  • Fax: 512-716-1890
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number1054252
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: