Provider Demographics
NPI:1124767629
Name:BOSWELL, CARLIE
Entity type:Individual
Prefix:
First Name:CARLIE
Middle Name:
Last Name:BOSWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7120 SE LEXINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-8766
Mailing Address - Country:US
Mailing Address - Phone:512-965-6596
Mailing Address - Fax:
Practice Address - Street 1:2507 CHRISTIE DRIVE
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034
Practice Address - Country:US
Practice Address - Phone:503-635-3416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist