Provider Demographics
NPI:1912112657
Name:BOSWELL, EDITH (MA, TLLP)
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:BOSWELL
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 LAUREL DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-3821
Mailing Address - Country:US
Mailing Address - Phone:248-879-1205
Mailing Address - Fax:
Practice Address - Street 1:2014 LAUREL DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-3821
Practice Address - Country:US
Practice Address - Phone:248-879-1205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012439103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical