=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720431992
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH BOSARGE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2016
-----------------------------------------------------
Last Update Date | 07/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 511 MAPLE LN
-----------------------------------------------------
City | OCEAN SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39564-9063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-872-8882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1541
-----------------------------------------------------
City | OCEAN SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39566-1541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-215-0815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | M8838
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C8838
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------