Provider Demographics
NPI:1699716704
Name:BOSWELL, LORI J (PT, CLT-LANA)
Entity type:Individual
Prefix:MS
First Name:LORI
Middle Name:J
Last Name:BOSWELL
Suffix:
Gender:F
Credentials:PT, CLT-LANA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 PICKLE RD
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:NC
Mailing Address - Zip Code:27576-6748
Mailing Address - Country:US
Mailing Address - Phone:919-284-1391
Mailing Address - Fax:
Practice Address - Street 1:1811 FOREST HILLS RD W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3412
Practice Address - Country:US
Practice Address - Phone:252-243-7400
Practice Address - Fax:252-243-3291
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6743225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC720777YMedicaid
NC0777YOtherBCBS GROUP NUMBER
NC34-6557Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER