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General NPI Number Information
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NPI Number | 1649647900
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Entity Type | Organization
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Legal Business Name | MARILYN BOSWORTH, SLP
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Dates
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Enumeration Date | 08/21/2015
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Last Update Date | 08/21/2015
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Provider Practice Location Address
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Address Line | 105 ALSACE CT
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32082-2950
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Country | US
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Telephone | 904-343-4727
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Fax |
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Provider Business Mailing Address
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Address Line | 105 ALSACE CT
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32082-2950
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Country | US
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Telephone | 904-343-4727
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JONATHAN WALTON BOSWORTH
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Credential | HUSBAND
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Telephone | 904-273-8266
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | SA6123
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License Number State | FL
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