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NPI Code Detail

MEDICARE: FRED A BOSWELL CSAC, ICS

MEDICARE: FRED A BOSWELL CSAC, ICS
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
1101YA0400XAddiction (Substance Use Disorder) Counselor11950-132WI

General Provider Information

NPI Number : 1366720484
Entity Type Code : Individual
Provider Name (Legal Business Name) : FRED A BOSWELL CSAC, ICS
Provider Business Mailing Address
First Line : 3707 N RICHARDS ST
Second Line :
City : MILWAUKEE
State : WI
Zip : 53212-1673
Country : US
Telephone Number : 414-967-7006
Fax Number : 414-967-7020
Provider Business Practice Location Address
First Line : 3707 N RICHARDS ST
Second Line :
City : MILWAUKEE
State : WI
Zip : 53212-1673
Country : US
Telephone Number : 414-967-7006
Fax Number : 414-967-7020
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/22/2011
Last Update Date : 04/30/2014

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