Provider Demographics
NPI:1841016797
Name:BOSHER, EVAN MATTHEW
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:MATTHEW
Last Name:BOSHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5527 DAYBREAK CT
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-4688
Mailing Address - Country:US
Mailing Address - Phone:760-696-8568
Mailing Address - Fax:
Practice Address - Street 1:9335 RESEDA BLVD STE 101
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-2977
Practice Address - Country:US
Practice Address - Phone:818-960-0633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician