Provider Demographics
NPI:1285887182
Name:BOSWELL, MATTHEW (MS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BOSWELL
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2266 N PROSPECT AVE
Mailing Address - Street 2:SUITE #605
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-6319
Mailing Address - Country:US
Mailing Address - Phone:414-289-0937
Mailing Address - Fax:414-289-0938
Practice Address - Street 1:2266 N PROSPECT AVE
Practice Address - Street 2:SUITE #605
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-6319
Practice Address - Country:US
Practice Address - Phone:414-289-0937
Practice Address - Fax:414-289-0938
Is Sole Proprietor?:No
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40977900Medicaid