=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831700103
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA G BOSWELL PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2020
-----------------------------------------------------
Last Update Date | 08/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 GOLD ST APT 106
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06519-1641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-210-9796
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 GOLD ST APT 106
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06519-1641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-210-9796
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TH0004X
-----------------------------------------------------
Taxonomy Name | Health Psychologist
-----------------------------------------------------
License Number | PST00249
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PST00249
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------