=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932329729
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESA MARIE BOSWORTH MA,CCC-A
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2007
-----------------------------------------------------
Last Update Date | 08/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1425 MICHIGAN NE SUITE A
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-459-4514
-----------------------------------------------------
Fax | 616-459-5001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1425 MICHIGAN NE SUITE A GRAND RAPIDS EAR NOSE & THROAT, PC
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-459-7749
-----------------------------------------------------
Fax | 616-459-5001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | 1601000098
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------