MEDICARE: GABRIELLE NICOLE BOSAK PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	12471	SC

General Provider Information

NPI Number	:	1356131452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIELLE NICOLE BOSAK PT, DPT

Provider Business Mailing Address
First Line	:	1401 CAMP RD APT B
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29412-3752
Country	:	US
Telephone Number	:	843-754-4431
Fax Number	:

Provider Business Practice Location Address
First Line	:	1014 SAINT ANDREWS BLVD STE 101
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-7177
Country	:	US
Telephone Number	:	843-985-0914
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2025
Last Update Date	:	05/12/2025

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