MEDICARE: BOSLEY ENTERPRISES LLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1457183139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOSLEY ENTERPRISES LLC

Provider Business Mailing Address
First Line	:	1109 WOODLAND XING
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-7239
Country	:	US
Telephone Number	:	260-440-0770
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 AIRPORT NORTH OFFICE PARK
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-6704
Country	:	US
Telephone Number	:	260-440-0770
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RAPHAEL BOSLEY
Credential	:	LMHC
Telephone Number	:	260-440-0770

Provider Enumeration Date	:	08/20/2024
Last Update Date	:	08/20/2024

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