MEDICARE: CAMILLE BOISVERT KO

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	225X00000X	Occupational Therapist	116669	TX

General Provider Information

NPI Number	:	1639560089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMILLE BOISVERT KO

Provider Business Mailing Address
First Line	:	305 NE LOOP 820
Second Line	:	BUSINESS TOWER 1, SUITE 200
City	:	HURST
State	:	TX
Zip	:	76053-7209
Country	:	US
Telephone Number	:	817-292-8787
Fax Number	:	817-789-6849

Provider Business Practice Location Address
First Line	:	930 W CENTERVILLE RD
Second Line	:	#930C
City	:	GARLAND
State	:	TX
Zip	:	75041-5823
Country	:	US
Telephone Number	:	972-303-7021
Fax Number	:

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

Provider Enumeration Date	:	02/06/2015
Last Update Date	:	12/31/2025

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Directions to “ CAMILLE BOISVERT KO ” Practice Location

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