Provider Demographics
NPI:1306906011
Name:BOSWORTH, THOMAS MATTHEW (MSW)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MATTHEW
Last Name:BOSWORTH
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 QUINCY ST # 215
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-3626
Mailing Address - Country:US
Mailing Address - Phone:605-343-7755
Mailing Address - Fax:605-721-8896
Practice Address - Street 1:420 QUINCY ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3626
Practice Address - Country:US
Practice Address - Phone:605-343-7755
Practice Address - Fax:605-716-0650
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2020-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD15901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6570593Medicaid