Provider Demographics
NPI:1396245403
Name:BOSTIC, LARHONDA RENEE
Entity type:Individual
Prefix:
First Name:LARHONDA
Middle Name:RENEE
Last Name:BOSTIC
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 1:500 MADISON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1230
Mailing Address - Country:US
Mailing Address - Phone:567-312-8700
Mailing Address - Fax:567-312-8793
Practice Address - Street 1:500 MADISON AVE STE 200
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-1230
Practice Address - Country:US
Practice Address - Phone:567-312-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 106S00000X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSZ262865Medicaid