Provider Demographics
NPI:1336245752
Name:BOSSARDT, RICHARD L (LCSW)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:L
Last Name:BOSSARDT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2085 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2085
Mailing Address - Country:US
Mailing Address - Phone:541-269-5333
Mailing Address - Fax:541-269-5609
Practice Address - Street 1:2085 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2085
Practice Address - Country:US
Practice Address - Phone:541-269-5333
Practice Address - Fax:541-269-5609
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3501941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR35 0194OtherCLINICAL SOCIAL WORKERS
OR35 0194OtherCLINICAL SOCIAL WORKERS